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THE   SURGICAL  ASSISTANT 


Digitized  by  tine  Internet  Archive 

in  2010  witin  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgicalassistanOObric 


The   Surgical    Assistant 


A  Manual  for  Students,  Practitioners,  Hospital 
Internes  and  Nurses 


BY 

WALTER  M.  BRICKNER,  B.  S.,  M.  D. 

NEW    YORK    CITY 


WITH   123  ORIGINAL   ILLUSTRATIONS 


^ 


PUBLISHED    BY    THE 

Internatioxal  Journal  of  Surgery  Co. 

medical  publishers 

100  willjam  stkeet,  ^■e^v  yokk 


COPYRIGHT,   1905, 

BY 

THE  INTERNATIONAL  JOURNAL  OF  SURGERY  CO. 


HOWARD  LILIENTHAL,  M.  D. 


AS    A    TOKEN    OF   PERSONAL   REGARD,    AND    AS   A 

TRIBUTE    TO     HIS     SURGICAL    SKILL, 

THIS    BOOK    IS    DEDICATED 


PREFACE. 

Surgical  text-books,  even  those  that  deal  most  minutely 
with  operative  technics,  make  but  scant  reference  to  the 
duties  of  the  surgeon's  assistants.  And  yet  the  skill  of  the 
assistants  is  scarcely  less  important  than  the  skill  of  the  sur- 
geon himself.  In  an  operation  the  surgeon  must  depend,  not 
only  upon  the  experience  and  the  caution  of  the  anesthetist, 
but  also  upon  the  familiarity  with  aseptic  details,  the  fore- 
sight and  adaptability,  and  the  coolness  in  emergency  of 
those  who  aid  him  in  the  mechanical  procedure  itself. 

If  we  except  a  brochure  by  Dr.  Carl  Lauenstein — "  Der 
Assistenzarzt  " — which  in  neither  scope  nor  execution  has 
anything  in  common  with  this  book,  nothing  known  to  the 
author  has  been  written  upon  this  important  subject.  The 
volume  he  presents  is  then,  a  pioneer,  and  as  such,  no  doubt, 
has  its  shortcomings. 

In  spite  of  these  he  believes  it  will  be  found  a  helpful 
guide — to  the  student  preparing  for  hospital  examinations 
or  substituting  in  hospital  or  dispensary  work;  to  the  hos- 
pital interne  who,  early  in  his  service,  unfamiliar  as  yet 
with  surgical  technics  or  even  with  the  names  and  forms 
of  many  surgical  appliances,  is,  for  a  time,  embarrassed 
by  the  awkwardness  of  his  untutored  hands  and  the  slowness 
of  his  untrained  eye ;  to  the  graduate  nurse  who,  trained  in 
the  hospital  operating-room  only  in  the  handing  of  sponges 
and  towels,  finds  herself  confronted  in  private  practice  with 
the  necessity  of  preparing  a  room  for  an  operation  and  very 
often  of  assisting  actively  in  the  operation  itself;  and  to 
the  general  practitioner^  as  a  volume  of  reference  to  aid  him 
in  maintaining  a  large  share  in  the  treatment  of  those  of 
his  patients  who  otherwise  would  pass  from  his  entirely  into 
Other  hands.      If,   in   emergency,   it  occasionally   becomes 

7 


8  Preface. 

imperative  for  one  not  thoroughly  trained  in  surgery  to  per- 
form a  major  operation,  how  much  more  often  will  it  be 
necessary  for  him  to  render  assistance  to  the  consultant 
whom  he  has  called  to  an  urgent  case!  Moreover,  the 
possession  of  ability  to  help  well  would  go  far  to  settle 
satisfactorily  the  questions  of  fees ;  for,  sharing  in  the  labor 
of  an  operation,  and  conducting  some  or  all  of  the  after- 
dressings,  are  rendering  to  both  patient  and  surgeon  definite 
and  valuable  services,  well  worthy  of  recognition. 

Essentially  a  technical  manual,  this  work  aims  to  be  thor- 
oughly practical,  its  object  being  to  present  clearly  and 
concisely  the  many  important  details  of  method,  the  valua- 
ble little  "  wrinkles,"  which,  familiar  enough  to  the  surgeon 
and  to  the  trained  assistant,  have  not  before  been  gathered 
together  in  print. 

The  latter  part  of  the  book  is  devoted  to  the  description, 
from  the  assistant's  standpoint,  of  various  operations,  step 
by  step.  For  this  purpose  there  are  selected  for  consider- 
ation only  those  operations  that  are  commonly  performed, 
those  that  typify  certain  groups  of  operations,  those  that 
constitute  important  emergencies,  and  those  that  require 
special  description. 

Manifestly  the  assistant's  manipulations  must  depend,  in 
large  part  at  least,  upon  the  operator's  methods;  but  since 
the  essential  and  the  commonly  adopted  technics  are  de- 
scribed it  ought  not  to  be  difficult  to  modify  them  to  suit 
the  needs  of  individual  cases. 

It  will  be  noted  that  most  of  the  descriptions  are  given 
as  though  but  one  assistant  (in  addition  to  the  anesthetist) 
were  present,  and  the  reader  may  sometimes  think  the  author 
has  forgotten  that  an  assistant  has  but  two  hands.  In  fact, 
however,  there  are  few  operations  that  cannot  be  conducted 
with  but  one  assistant,  and,  in  emergency,  only  one  may  be 
available.  In  such  cases  the  assistant  must  often  make  his 
two  hands  do  the  work  of  three  or  four.  When,  however, 
a  full  quota  of  assistants  is  present  the  proper  distribution 
of  their  duties  may  be  derived  from  a  reference  to  the 
earlier  chapters. 


Preface.  9 

Especial  care  has  been  taken  to  make  the  index  useful. 
It  is  hoped  that  the  appendix  containing  the  formulary  for 
the  preparation  of  ligature  material,  surgical  dressings,  etc., 
will  also  prove  useful.  While  illustrations  of  the  instru- 
ments in  constant  use  are  quite  essential  to  a  hand-book 
of  this  character,  it  has  been  thought  best  to  print  them 
together  in  a  second  appendix.  The  electrotypes  for  most 
of  these  pictures  have  been  kindly  furnished  by  Messrs. 
George  Tiemann  &  Co.  All  the  other  illustrations  in  the 
book  are  the  work  of  Dr.  Erwin  Reissman,  to  whom  the 
author  expresses  his  appreciation.  He  would  also  thank 
here  Drs.  Arpad  G.  Gerster,  Howard  Lilienthal,  and  Paul 
J.  Rosenheim  for  suggestions,  and  Dr.  Joseph  MacDonald, 
jr.,  for  his  uniform  courtesy  and  interest  in  the  publication 
of  the  work. 

W.  M.  B. 

30  West  Ninety-second  Street,  New  York, 
April  15,  1905. 


CONTENTS. 

PART   I. 

Chapter  I. 

PAGE 

THE  CONDUCT  OF  THE  ASSISTANT  AND  HIS 
RELATIONS  WITH  THE  SURGEON  AND  THE 
PATIENT 27 

Chapter  II. 

THE  HOSPITAL  INTERNE. 

Relations  with  Superior  and  Subordinate  Officers,  Nurses, 
Patients — The  House  Surgeon — Rounds— Dressings — 
Examinations — Observation  of  Symptoms— Care  of 
Histories .         .         .32 

Chapter  III. 

ASSISTANCE  IN  EXAMINATIONS  AND  DRESSINGS. 

Examinations— Fractures     and     Dislocations — Change    of 

Dressings yi 

Chapter  IV. 

PREPARATIONS  FOR  AN  OPERATION— THE  ROOM. 

General  Considerations— Sj'stem— Preparations  in  Detail  .       53 

Chapter  V. 

PREPARATIONS  FOR  AN  OPERATION— THE  PATIENT. 
THE  ASSISTANT  HIMSELF  ;  TECHNICS  OF  ASEPSIS. 

Carrying  the  Patient— Aseptic  Preparations  in  Detail- 
Aseptic  "  Don'ts"        68 

11 


12  Contents. 

Chapter  VI. 
THE  ANESTHETIST. 

PAGE 

Effects  of  Chloroform,  of  Ether,  of  their  Mixtures;  Indica- 
tions and  Contra-indications  for  Each — Technics  of  An- 
esthetizing— Symptoms  to  be  Observed;  their  Indica- 
tions; Treatment — Emergencies — Individual  Methods 
of  Administering  the  Various  Anesthetics;  Chloroform; 
Ether;  Gas  and  Ether;  Chloroform-Ether  Mixtures; 
Nitrous  Oxid;  Nitrous  Oxid  and  Oxygen;  Ethyl  Chlo- 
rid;  Ethyl  Bromid — Obstetric  Narcosis   ,        .        .         .81 

Chapter  VII. 

PREPARATION    AND    PRESERVATION   OF   SURGICAL 
INSTRUMENTS  AND   ACCESSORIES. 

Sterilization   of  the  Various  Instruments,  etc. — Cleansing 

and  Preservation 102 

Chapter  VIII. 
••  HANDING  INSTRUMENTS."  114 

Chapter  IX. 

ASSISTANCE  AT  THE  WOUND. 

General  Considerations— Use  of  the  Hands— The  Incision — 
Sponging— Retracting — Dissection — Hemostasis;  Ma- 
nipulation of  Ligatures— Suturing— Removing  Sutures 
— Irrigating         . 130 

Chapter  X. 

IMMEDIATE  POST-OPERATIVE  CARE  OF  THE 
PATIENT. 

Clothing— Removal  from  Table— The  Room— The  Bed—. 
Arrangement  of  the  Patient  in  Bed— Pain  and  Restless- 
ness— Tightness  of  the  Dressing — Vomiting — Feeding— 
Singultus— Urination— Shock  and  Concealed  Hemor- 
rhage; Differential  Diagnosis— Treatment  of  Shock- 
Treatment  of  Hemorrhage;  External  Hemorrhage; 
Bleeding  from  Wounds  in  General;  Anterior  Naris;  Pos- 
terior Naris;  Tonsil;  Intercostal  Vessels;  Intra-abdom- 


Contents.  13 

PAGE 

mal  Bleeding;  Kidney;  Renal  Vessels;  Bladder;  Peri- 
neum; Rectum;  Uterus  (post-partum);  Cervix  Uteri — 
After-Treatment  of  Severe  Hemorrhage — Pulmonary- 
Edema;  Use  of  Cups;  Phlebotomy— Uremic  Convul- 
sions—Poisoning by  the  Absorption  of  Antiseptics; 
Carbolic  Acid;  Bichlorid  of  Mercury;  Iodoform      .        .     147 


PART  II. 

Chapter  XI. 

OPERATIONS  UPON  THE  HEAD. 

The  Cranium;  Trephining— Mastoid  Operations  .         .        .163 

Chapter  XII. 

OPERATIONS  UPON  THE  HEAD  {Continued). 

Ophthalmic  Operations— Extraction  of  Cataract— Iridec- 
tomy— Strabismus— Enucleation— Eye  Dressings — Re- 
moval of  the  Upper  Jaw      .        .  .        .        ,        .171 

Chapter  XIII. 

OPERATIONS   UPON  THE  THROAT,   THE  NECK  AND 
THE  CHEST. 

Removal  of  Pharyngeal  Adenoids — Retropharyngeal  Ab- 
scess— External  Esophagotomy;  Thyroidectomy;  Re- 
moval of  Glands  and  New  Growths;  Operations  upon 
Vessels  and  Nerves— Tracheotomy — Breast  Amputa- 
tion— Empyema  Thoracis 177 

Chapter  XIV. 

ABDOMINAL  OPERATIONS. 

Preparation  of  the  Field— Armamentarium — Dissection 
of  the  Abdominal  Wall— Opening  the  Peritoneal 
Cavity — Exposing  the  Viscera — Pads  and  Packings — 
Suturing  the  Abdominal  Wall— The  Dressing       .        .       184 


14  Contents. 

Chapter  XV. 

ABDOMINAL  OPERATIONS  {Continued). 

Exploratory  Laparotomy — Appendicitis— General  Peritoni- 
tis— Lavage  of  the  Stomach 196 

Chapter  XVI. 

ABDOMINAL  OPERATIONS  {Continued). 
Operations  upon  the  Gall-bladder  and  Gall  Ducts — Chole- 
cystostomy;  Cholecystotomy — Choledochotomy — Chole- 
cystectomy— Cyst  of  the  Liver — Abscess  of  the  Liver — 
Subphrenic  Abscess— Resection  of  the  Liver  (new- 
growth)       202 

Chapter  XVII. 
ABDOMINAL  OPERATIONS  {Continued). 
Operations  upon  the  Stomach  and  Intestines— Gastrostomy 
— Internal     Esophagotomy — Gastrorrhaphy;     Enteror-  . 
rhaphy  —  Gastro-enterostomy;     Gastrectomy;    Pyloro- 
plasty; Pylorectomy— Colostomy— Intestinal  Resection 
— Intestinal  Anastomosis 207 

Chapter  XVIII. 
ABDOMINAL  OPERATIONS  {Contiftued). 
Operations  upon  the  Female   Pelvic   Organs,  Abdominal 
Route— Ovariotomy;     Salpingectomy— Cysts— Abscess 
— Ectopic  Gestation — Hysterectomy — Cesarean  Section     218 

Chapter  XIX. 

ALEXANDER'S  OPERATION  OF  SHORTENING  THE 
UTERINE  ROUND  LIGAMENTS.    HERNIOTOMY. 
Alexander's     Operation— Ventral      Herniotomy— Inguinal 

Herniotomy— Femoral  Herniotomy        ....       225 

Chapter  XX. 
OPERATIONS  UPON  THE  KIDNEY  AND  URETER. 
Lumbar    Route — Position  —  Nephrotomy  —  Nephrectomy — 
Nephropexy— Abdominal  Route— Operations  upon  the 
Ureter       .,»...,,..     235 


Contents,  15 

Chapter  XXI. 
OPERATIONS  UPON  THE   BLADDER  AND   URETHRA. 

PAGE 

Cystoscopy  in  the  Male — Endoscopy — Cystoscopy  in  the 
Female — Suprapubic  Cystotomy;  Lithotomy;  Prosta- 
tectomy; Neoplasm;  Ulcer — Drainage — Internal  Ure- 
throtomy— External  Urethrotomy;  Perineal  Section — 
Manipulation  of  Steel  Sounds 241 


Chapter  XXII. 
OPERATIONS  IN  AND  ABOUT  THE  VAGINA. 
Position  —  Preparation  —  Curettage  —  Trachelorrhaphy  — 
Hysterectomy — Drainage  of  Pelvic  Abscess,  etc. — Plas- 
tic Operations— Anterior  Colporrhaphy — Posterior  Col- 
porrhaphy;  Perineorrhaphy 257 


Chapter  XXIII. 
RECTAL    OPERATIONS. 
Position — Preparation— Dressing — Radical   Operations   for 

Hemorrhoids— Stricture — Fistulo  in  Ano         .        .        .     277 


Chapter  XXIV. 

OPERATIONS  UPON  THE  EXTREMITIES. 

Amputations — Osteotomy 286 

Chapter  XXV. 

SKIN-GRAFTING.        INTRAVENEOUS       INFUSION. 

SUBCUTANEOUS  INFUSION 299 

APPENDICES. 

Appendix  I. 

THE  PRELIMINARY  PREPARATION  AND  ROUTINE 

AFTER-TREATMENT  OF   OPERATIVE  CASES  .     3x1 


16  Contents. 

THE   PREPARATION  OF   SURGICAL   MATERIALS; 
FORMULARY. 

PAGE 

Sutures  and  Ligatures  —  Sea-Sponges — Rubber  Tissue; 
Gutta  percha  Solutions,  etc. — Bone  Chips — Paraffin  Mix- 
tures— Bone  Wax — Bandages — Dressings — Towels  and 
Gowns— Surgical  Solutions — Battery  Fluids — Enemata    314 

Appendix  II. 
ILLUSTRATIONS  OF  SURGICAL  INSTRUMENTS         337 

INDEX.  355 


LIST   OF   ILLUSTRATIONS. 


FIGURE 

1.  Manner  of  holding  a  child  firmly  in  the  sitting  pos 

ture        ....-•••• 

2.  Manner  of  holding  a  child  upon  a  table 

3.  Proper  manner  of  holding  foot  during  application  of 

bandage         

4.  Maintaining  reduction  of  forearm  fracture   , 

5.  Triangular  cardboard  axillary  pad 

6.  Padded  straight  splint 

7.  Plaster  dressing— arrangement  for  making  soft  cuff 

8.  Freeing  bandage  of  frayed  edges 

9.  Handing  plaster  bandage 

10.  Plaster  dressing — smooth  cuff  formed  . 

ir.  Arrangement  for  dressing  wound  of  neck     . 

12.  Scheme  of  operating  room  arranged  in  private  dwell 

ing 

13.  Improvised  Trendelenburg  table    .... 

14.  Table  arranged  for  operation  in  lithotomy  position 

15.  Arrangement  for  anesthetist  .... 

16.  Arrangement  of  accessories  on  mantel-shelf 

17.  Arrangement  of  instrument  table 

18.  Arrangement  of  table  for  second  assistant  (nurse) 

19.  Lifting  and  carrying  a  patient       .         . 

20.  Transportation  of  a  patient  by  two  men 

21.  Arrangement  of  sterilized  towels  for  laparotomy 

22.  The  assistant  "  scrubbed  up  "  and  ready  for  opera 

tion 

23.  Administration  of  chloroform— holding  jaw  forward 

etc. 

24.  Sponging  mucus  from  the  pharynx 

25.  Administration  of  gas  and  ether    .... 

26.  Testing  iridectome  on  "  drum  "     .        .        .         . 

27.  Repairing  aspirating  syringe  with  leather  packing 

28.  Surgical  catgut— scale  of  sizes        .... 

29.  Squeezing  end  of  catgut  for  insertion  in  eye  of  needle     11 

17 


37 
38 

39 
41 
42 

43 
45 
46 

47 
49 
51 

59 
60 
61 
63 
64 
66 
67 
69 
70 
71 

73 


90 

98 

107 

no 

117 


18  List  of  Illustrations. 


FIGURE  PAGE 

30.  Twisting  silkworm-gut  suture 119 

31.  "  Button  suture " 120 

32.  Handing  gauze  packing 121 

33.  Handing  "  cigarette  "  drain    ......  122 

34.  Preparation  of  drainage  tube          .....  123 

35.  Fenestrated  drainage  tube      .         .         .         .         .         .  123 

36.  Handing  drainage  tube  on  probe  .        .        .        .         .124 

37.  The  clove  hitch         ........  125 

38.  Incorrect  manner  of  handing  chisel   and  mallet  to 

operator         .........  125 

39.  Correct  manner  of  handing  chisel  and  mallet       .        .126 

40.  Handing  suture  and  forceps  .        .        ...         .         .  127 

41.  Cotton  sponges 128 

42.  Incorrect  manner  of  holding  retractors         .        .         .  131 

43.  Proper  disposition  of  hands  and  arms  in  holding  re- 

tractors            131 

44.  Stretching  the  skin  to  facilitate  primary  incision         .  132 

45.  Retractor  exposing  to  view  a  large  surface  through  a 

small  opening       .       ' 134 

46.  Dissection  between  mouse-tooth  forceps       .        .         .  136 

47.  Manipulation  of  hemostat  and  scissors  in  application 

of  a  ligature           ........  138 

48.  Surgeon's  knot;  flat  knot;  granny  knot          .         .         .  139 

49.  Application  of  "  chain  ligature  "  to  omentum       .         .  141 

50.  Coaptation  of  edges  by  traction  with  tenacula     .        .  142 

51.  Coaptation  of  edges  by  traction  with  two  forceps        .  142 

52.  Assistant's  manipulations  during  introduction  of  con- 

tinuous suture 143 

53.  Lifting  skin  edges  with  one  forceps  for  introduction 

of  suture 144 

54.  Eversion  of  wound  edges  during  suturing    .        .        .  145 

55.  Tying  button  sutiires 145 

56.  Elevation  of  foot  of  bed  with  chair ;  arrangement  of 

bed 152 

57.  Position  of  head  for  operation  on  lower  jaw  or  neck  ; 

for  mastoid  operation 167 

58.  Gauze  shaped  for  mastoid  dressing        .        .        .         .  169 

59.  Mastoid  dressing  held  with  starch  bandage          .        .  170 

60.  Manner  of  passing  instruments  and  illuminating  for 

cataract  operation 172 

61.  Eye  pads  in  a  shallow  basin  of  boracic  acid  solution  .  173 


List  of  Illustrations.  19 

FIGURE  PAGE 

62.  Dressing  and  bandage  of  one  eye  ....     174 

63.  Application  of  dressing  after  breast  operation     .         .     181 

64.  Position  of  patient  for  empyema  operation — rib  drawn 

up  with  hook  ........     182 

65.  "  Trap-door  incision  " — rectus  abdominis  exposed       .     185 

66.  "  Trap-door   incision  " — posterior   rectus    sheath    ex- 

posed      186 

67.  "  Trap-door  incision  " — posterior  i-ectus  sheath  divided 

between  two  forceps 187 

68.  Enlarging  peritoneal  opening— protecting  underlying 

viscera  .........     188 

69.  Lifting  up  with  retractors  to  expose  a  large  visceral 

surface 189 

70.  Tying  laparotomy  straps 194 

71.  A  method  of  applying  adhesive  straps  over  abdom- 

inal dressing 195 

72.  Gauze  packing  inserted  and  cecum  drawn  into  wound     197 

73.  Assistant  lifting  up  appendix  while  operator  inserts 

double  ligature 198 

74.  Amputation  of  appendix 199 

75.  Assistant  holding  patient  on  his  side— draining  gall 

bladder  into  pus  basin 203 

76.  Inguinal  colostomy — rod  in  place;  anchorage       .         .     210 

77.  Manner  of  handing  half  of  Murphy  button  .         .         ,     216 

78.  Bassini's  operation — retraction  of  divided  external  ob- 

lique, exposing  sac;  opening  sac  between  forceps 

79.  Bassini's  operation — separation  of  sac  from  cord 


85 


87 


Bassini's  operation — introduction  of  deep  sutures 
Bassini's  operation — second   suture    layer,    restoring 

external  oblique 231 

Turns  of  bandage  after  inguinal  herniotomy  .  .  232 
Perineal  turns  of  bandage  after  inguinal  herniotomy  233 
Assistant  pushing  up  kidney  by  pressure  on  abdomen 

cushion  under  lower  loin     ......     237 

Suprapubic  C3'^stotomy     .......     246 

Arrangement  of  syphon  for  suprapubic  drainage  of 

bladder 249 

Manner  of  holding  penis,  scrotum,  and  urethral  sound 

in  external  urethrotomy 252 

Arrangement  of  table,  towels,  and  chairs  for  perineal 

operation      , 258 


228 
229 
230 


20  List  of  Illustrations. 

FIGURE  PAGE 

8g.     Manner  of  applying  Clover's  crutch      ....  259 

90.  Disposition  of  operator  and  assistant  in  vaginal  and 

perineal  operations 260 

91.  Disposition  of  surgeon,  assistant,  and  anesthetist  in 

trachelorrhaphy 263 

92.  Trachelorrhaphy  —  assistant    sponging    v^^ound    and 

clamping  sutures 264 

93.  Drainage  of  pelvic  abscess — retracting  vaginal  walls; 

drainage  tube  inserted  in  dressing  forceps       .         .  267 

94.  Dissection  of  cystocele  flap 269 

95.  Holding  loops  of  suture  in  anterior  colporrhaphy        .  271 

96.  Dissection  of  rectocele  flap 272 

97.  Dissection   of  rectocele   flap — assistant    manipulates 

both  forceps;  surgeon's  finger  in  rectum           .         .  273 

98.  Posterior  colporrhaphy — catching  up  loops  of  suture  274 

99.  Insertion  of  perineal  sutures           .....  276 

•  277 

.  278 

.  279 

.  280 

.  281 

.  282 

.  285 

.  287 


100.  Sims'  position — rectal  examination 

loi.  Manner  of  stretching  sphincter  ani 

102.  Tampon  canula        ..... 

103.  Rectal  dressing 

104.  Clamp  and  cautery  operation — clamping 

105.  Clamp  and  cautery  operation — cauterizing 

106.  "  Canule  a  chemise "       .         .         .        . 

107.  Two-tailed  cloth  retractor  for  amputation 

108.  Three-tailed  cloth  retractor  for  amputation  .         .     287 

109.  Driving  blood  from  the  limb  with  rubber  bandage      .     289 
no.  Martin's  rubber  bandage  applied  to  arm       .        .         .     290 

111.  Application  of  constrictor  to  thigh        ....     291 

112.  Positionof  lower  extremities  in  amputation  of  the  thigh     292 

113.  Bone  exposed  for  sawing 293 

114.  Stump  supported  and  bloodvessels  exposed         .         .     294 

115.  Preparation  of  a  finger  for  amputation  .         .         .     296 

116.  Osteomyelitis — removing  bits  of  bone  and   sponging 

pus,  etc •     297 

117.  Skin-grafting — stretching  skin  with  McBurney's  hooks    300 

118.  Skin-grafting — stretching  skin  with  the  hands    .         .     300 

119.  Intravenous  infusion — arrangement  of  arm  and  of  ac- 

cessories         303 

120.  Intravenous  infusion — opening  the  vein        .         .         .     305 

121.  Intravenous  infusion — introducing  the  cauula     ..       .     306 

122.  Subcutaneous  saline  infusion  .        .        .        .        .     308 


List  of  Illustrations. 


21 


APPENDIX. 

i-IGURE 

1.  Yankauer's  chloroform  mask 

2.  AUis'  ether  inhaler 

3.  Bennett's  apparatus 

4.  Ware's  ethyl  chlorid  mask 

5.  Denhard's  mouth-gag 

6.  Paquelin's  cautery  . 

7.  Gerster's  iodoform  duste 

8.  Dieulafoy's  aspirator 

9.  Trocar  and  canula  . 

10.  Volkmann's  spoon   . 

11.  Scalpels    . 

12.  Bistouries 

13.  Tenotome 

14.  Flexible  probes 

15.  Fluhrer's  aluminum  prob 

16.  Grooved  director 

17.  Amputating  knife    . 

18.  Catlin  (interosseous  knife) 

19.  Curved  scissors 

20.  Angular  scissors 

21.  Heavy  bandage  shears 

22.  One-pronged  retractor 

23.  Two-pronged  retractor 

24.  Small  blunt  retractor 

25.  Large  (abdominal)  blunt  retracto 

26.  Four-pronged  retractor 

27.  Forms  of  surgical  needle 

28.  Peaslee  needle 

29.  Aneurism  needle 

30.  Ligature  carrier 

31.  Dieffenbach's  needle  holder  . 

32.  Wyeth's  needle  holder    . 

33.  Hagedorn's  needle  holder 

34.  Anatomical  ("  thumb  ")  forceps 

35.  Tissue  forceps 

36.  Dressing  forceps 

37.  Slender  (vaginal)  dressing  forceps 

38.  Bullet  forceps 

39.  Sponge  forceps 

40.  Gerster's  artery  forceps 


PAGE 

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22 


List  of  Illustrations. 


41.  Esmarch's  bulldog  artery  forceps 

42.  Pean's  artery  forceps 

43.  Serrefins 

44.  Spencer  Wells'  straight  clamp 

45.  Skene's  curved  clamp 

46.  Spencer  Wells'  T-shaped  clamp 

47.  Angiotribe 

48.  Murphy's  button 

49.  Tracheal  canula 

50.  Nasal  speculum 

51.  Polypus  snare  . 

52.  Bosworth's  nasal  saw 

53.  Snellen's  entropion  forceps    . 

54.  Rack  for  ophthalmic  instruments 

55.  Knapp's  trachoma  forceps 

56.  Gottstein's  adenoid  curette     . 

57.  Bowman's  lachrymal  probes  . 

58.  Wire  eye  speculum 

59.  Iris  scissors       .... 

60.  Beer's  keratoma       ... 

61.  Graefe's  linear  cataract  knife 

62.  Knapp's  cystotome 

63.  Levi's  fenestrated  lens  spoon 

64.  Wilde's  tubular  aural  specula 

65.  Angular  ear  forceps 

66.  Mastoid  mallet 

67.  Mastoid  chisels 

68.  Mastoid  gouge 

69.  Keyhole  saw     . 

70.  Flat  bone  saw  . 

71.  Ferguson's  lion-jaw  bone-holding  forceps 

72.  Markoe's  sequestrum  forceps 

73.  Listen's  bone-cutting  forceps 

74.  Costotome  ... 

75.  MacEwen's  osteotome     . 

76.  Hamilton's  bone  drills    . 

77.  Sharp  bone  spoon;  periosteal  elevator 

78.  French  and  English  urethral  scales 

79.  Olive-tipped  catheter 

80.  Olivary  bougie  .... 

81.  Woven  catheter       .... 


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List  of  Illustrations.  23 

FIGURE  PAGE 

82.  Bougie  a  bonle 347 

83.  Phimosis  clamp 347 

84.  Filiform  bougies      .        .        .        .        .        .        .        .  348 

85.  Filiform  bougies 348 

86.  Ultzmann  urethral  syringe 348 

87.  Otis'  urethrometer 348 

88.  Thompson's  stone  searcher 348 

89.  Thompson's  lithotrite 348 

90.  Olive-tipped  catheter 348 

91.  Otis'  urethrotome 348 

92.  Maissoneuve's  urethrotome 348 

93.  Endoscope 349 

94.  Wheelhouse's  staff 349 

95.  Teale's  probe-gorget  (urethral  director)        .        .        .  349 

96.  Stone  forceps 349 

97.  Clover's  crutch  (Peter's) 349 

98.  Tenaculum        . 350 

99.  Volsellum         .........  350 

100.  Sims'  vpire  adjuster 350 

loi.  Uterine  sound 350 

102.  Sharp  uterine  curette 350 

103.  Dull  uterine  curette         .......  350 

104.  Palmer's  cervix  dilator 350 

105.  Goodell's  cervix  dilator 350 

106.  Recurrent  uterine  douche  nozzle 351 

107.  Sims'  vaginal  depressor 351 

108.  Garrigues'  weighted  speculum 351 

109.  Vaginal  spatula 351 

no.  Ferguson's  cylindrical  vaginal  speculum      .        .        .  351 

111.  Sims'  vaginal  speculum 351 

112.  Brewer's  bivalve  vaginal  speculum       ....  352 

113.  Bivalve  rectal  speculum 352 

114.  Ashton's  fenestrated  rectal  speculum   ....  352 

115.  Smith's  pile  clamp 352 

116.  English  rectal  bougies 352 


PART    I. 


THE  SURGICAL  ASSISTANT. 


PART  ONE. 

CHAPTER   I. 

THE    CONDUCT    OF    THE    ASSISTANT    AND    HIS   RELA- 
TIONS  WITH    THE    SURGEON    AND   THE 
PATIENT. 

Since  many  minor  procedures  and  almost  all  major  ones 
are  impossible  to  the  surgeon  without  help,  and  since  upon 
the  skill  and  care  with  which  that  help  is  rendered  depend 
in  no  small  degree  the  comfort  and  the  safety  of  the  patient, 
the  surgical  assistant  may  come  at  once  to  a  realization  of 
his  importance  to  both  surgeon  and  patient  and  to  an  appre- 
ciation of  his  proper  relation  to  each  of  them.  Primarily  for 
the  purpose  of  serving  another's  needs,  his  greatest  use- 
fulness will  lie  in  forestalling  them.  However  simple  or 
mechanical  his  duty  may  be  on  any  occasion,  he  will  always 
find  it  is  best  performed  by  observing  closely  conditions  as 
they  are  developed  and  requirements  as  they  appear.  Manu- 
ally, he  must  help  in  the  procedure ;  mentally,  he  must  him- 
self undertake  it ;  he  should  be  not  a  pair  of  hands  alone  but 
a  brain  as  well.  His  usefulness  thus  developed,  he  is  often 
in  a  position  to  make  a  suggestion  that  may  help  the  solution 
of  a  knotty  problem.  This  is  especially  true  when,  as  should 
often  be  the  case,  the  patient's  physician  is,  for  the  nonce, 
the  surgeon's  helper,  for  he  continues  as  medical  adviser 
even  while  his  patient  is  upon  the  operating  table ;  and  while 
technically  he  is  assisting  the  surgeon,  in  a  broader  sense 
the  surgeon  is  merely  assisting  him. 

27 


28  The  Surgical  Assistant. 

If,  in  the  light  of  his  greater  experience,  the  surgeon 
deems  unworthy  of  adoption  any  suggestion,  however  sensi- 
ble, that  should  seldom  be  a  cause  for  offense.  During  oper- 
f  ations  especially,  the  assistant  will  do  well  to  keep  his  mouth 
'  closed  and  his  eyes  open.  If  he  observe  this  rule,  both  as  a 
matter  of  decorum  and  as  an  aseptic  principle,  an  occasional 
suggestion,  introduced  deferentially,  will  be  regarded  with 
respect, — otherwise  it  will  be  as  unwelcome  as  it  is  apt  to  be 
unwise. 

It  is  scarcely  appropriate  to  dwell  here  upon  the  necessity 
of  being  prepared  to  inform  the  consultant  surgeon  of  every 
detail  of  a  case  that  may  be  of  importance  to  him  in  forming 
his  opinion.  This  information  is  all  the  more  valuable  when 
it  is  a  carefully  written  record.  It  is  not  less  important  to 
save  for  his  own  observation  stools,  vomits,  uterine  or  other 
discharges,  etc.,  even  if  they  are  of  only  negative  value.  The 
lack  of  a  thorough  urinary  report  may  embarrass  the  consult- 
ant very  seriously.  It  will  in  many  instances  prove  embar- 
/  rassing  to  him,  too,  if  there  are  not  also  prepared  for  him 
such  paraphernalia  as  may  be  necessary  for  his  examination. 
Thus,  if  he  may  desire  to  aspirate  a  doubtful  swelling,  there 
should  be  ready :  soap  and  water,  a  brush,  alcohol  or  ether 
(or  both),  and  sublimate  solution,  for  disinfecting  the  area 
to  be  punctured,  and  similar  materials  for  sterilizing  his 
hands;  a  sterile  needle  and  syringe  (which  should  be  proven 
to  be  in  working  order  by  actual  test)  ;  a  porcelain  or  white 
enamelled  dish  to  receive  the  contents  of  the  syringe  when 
they  are  expelled  for  examination,  or,  lacking  this,  a  glass 
dish  beneath  which  may  be  fastened  a  disc  of  white  paper; 
a  small  dressing,  a  few  towels,  and  some  absorbent  cotton. 
All  these  things  should  be  near  at  hand  but,  until  needed, 
they  should  not  be  within  the  patient's  sight.  The  require- 
ments for  other  manipulations  will  be  considered  later. 

A  preparation  of  the  patient's  body  for  examination  is 
seldom  necessary  and  often  inadvisable,  for  it  is  best  for  the 
surgeon  to  see  things  in  their  actual  condition.  It  would, 
for  example,  be  unwise  to  administer  a  douche  before  a  vagi- 
nal inspection.     On  the  other  hand,  an  examination  of  the 


The  Conduct  of  the  Assistant.  29 

abdomen  may  be  difficult  because  of  tympanites  that  might 
have  been  relieved  by  a  preliminary  purgative. 

Often  the  assistant  will  be  called  upon  to  prepare  for  an 
examination  or  for  some  minor  procedure  hastily,  and  after 
the  surgeon  has  arrived.  Here  he  must  use  nice  judgment 
to  secure  the  greatest  convenience  to  the  surgeon  with  the 
least  confusion  in  the  household.  By  improvising,  and  by  / 
adapting  things  at  hand  to  his  needs,  he  may  avoid  a  scurry- 
ing'about  that  is  sure  to  distress  the  patient  and  to  annoy 
his  relatives.  On  the  other  hand,  it  is  better  to  send  to  the 
kitchen  for  a  table  or  a  chair  than  to  put  bottles  or  basins 
upon  polished  or  upholstered  furniture.  Stains  and  scratches 
are  unpardonable,  and  they  are  lasting  and  unpleasant 
reminders  of  a  visit  that  under  any  circumstances  was  antici- 
pated with  fear  and,  often,  is  recalled  with  distress. 

In  most  instances,  too,  it  is  better  to  trouble  the  family  for 
a  stone  or  china  dish,  rather  than  spoil  even  a  cheap  unenam- 
elled  metal  one  with  a  mercurial  solution.  It  is  the  assistant's 
business  to  see  that  the  patient's  body,  clothing  and  bed- 
covers are  properly  protected  against  soiling  by  blood,  pus, 
or  other  fluid.  Apiece  of  oilcloth  will  suffice  if  rubber  sheet- 
ing is  unavailable  or,  lacking  both,  several  towels  should  be 
used  to  protect  the  part  most  apt  to  be  soiled.  A  round 
basin  held  against  the  body  almost  invariably  fails  to  catch 
discharges.  If  a  kidney-shaped  receptacle  (pus  basin)  is 
not  at  hand,  absorbent  cotton  or  towels  should  be  used  to  / 
receive  a  discharge  not  too  profuse.  Blood-stained,  soiled 
towels,  etc.,  should  be  dropped  into  a  paper  bag  or  a  basin, 
which  may  be  pushed  out  of  sight  or  covered  with  a  cloth  and 
carried  from  the  room.  When  using  plaster  of  Paris,  no 
protection  of  the  patient  and  his  surroundings  from  the 
spattering  drops  can  be  too  careful.  Plaster  of  Paris  is  no 
more  desired  on  the  carpet  or  furniture  than  are  stains  of 
blood  or  pus,  and  however  much  the  patient  may  politely 
insist  that  "  it  doesn't  matter  a  bit,"  he  is  not  apt  to  mean  it. 
Even  if  it  "  doesn't  matter  "  to  him,  it  should  to  the  physi- 
cian, for  carelessness  in  these  particulars  is  as  much  bad  tech-  / 
nics  as  is  awkwardness  in  operative  manipulations.     It  is  not  ' 


30  The  Surgical  Assistant. 

hard  to  believe,  too,  that  despite  his  protestations  the  patient 
will  conclude  to  employ  in  the  future  a  surgeon  whose  repu- 
/  tation  for  skill  may  be  less,  but  whose  tidiness  is  more  in 
evidence,  and  whoever  may  be  at  fault,  he  is  not  apt  to  think 
kindly  of  either  the  surgeon  or  his  assistant,  if  they  leave  him 
wet,  soiled  and  dishevelled. 
,  (  The  assistant  should  observe  the  utmost  gentleness.  This 
I  Secures  the  patient's  confidence  and  prepares  him  to  bear 
with  equanimity  such  pain  as  is  unavoidable.  It  will  prob- 
ably be  distressing  to  pass  an  instrument  before  the  patient's 
eyes,  and  it  is  certainly  awkward  to  reach  across  his  body 
for  something  that  could  just  as  well  have  been  placed  else- 
where. A  speculum  that  is  cold,  or  too  hot,  or  dripping  wet, 
or  too  freely  smeared  with  vaselin  is  sure  to  cause  dis- 
comfort. 

When  it  is  necessary  to  wear  a  rubber  apron  it  is  always 
best  to  cover  this  with  a  white  gown,  for  rolled  shirtsleeves 
look  ungenteel  and  the  apron  appears  too  formidable,  while 
a  white  gown  gives  the  impression  that  it  is  worn  as  much 
for  the  patient's  sake  as  for  the  protection  of  the  surgeon's 
clothing.  In  this  connection  it  must  be  remembered  that  the 
average  layman  has  a  very  fair  idea  of  the  principles  of 
asepsis,  and  decided  and  proper  notions  of  surgical  cleanli- 
ness. However  simple  the  procedure  at  hand  may  be,  it  very 
properly  produces  the  best  impression  to  have  everything 
used  conform  with  these  quite  correct  notions. 
/  A  small  amount  of  blood  will  produce  a  large  stain,  and  a 
,'  small  instrument  may  provoke  considerable  fear ;  it  is,  there- 
fore, always  best  to  keep  both  implements  and  soiled  dress- 
ings out  of  sight  as  much  as  possible  and  to  remove  all  of 
them  as  soon  as  this  can  be  done. 
I  However  hasty  an  assistant's  preparations,  they  should 
f  never  be  ostentatious.  He  appears  most  dignified  when  his 
bearing  is  most  modest.  Let  him  secure  what  he  wants 
quietly,  making  his  requests  in  an  undertone  and  beyond 
the  patient's  hearing.  His  preparations,  too,  can  be  com- 
pleted with  no  disturbance  to  the  surgeon.  There  is  seldom 
need  of  asking  him  for  instructions;  certainly  no  need  of 


The  Conduct  of  the  Assistant.  31 

asking  him  aloud.     He  should  make  ready  what  will  be 
needed,  and  what  may  be  needed. 

If  a  nurse  be  present,  her  position  should  not  be  made  an 
opportunity  to  exhibit  authority.  Orders  ought  to  be  given 
to  her  in  a  low  voice  and  carried  out  as  quietly  as  the  assist- 
ant himself  is  working.  She  should  be  given  the  same 
opportunity  to  forestall  the  assistant's  wishes  as  the  assistant 
himself  likes  to  enjoy  in  anticipating  the  surgeon's  needs. 

If  the  assistant  observes  something  of  importance  that  the 
surgeon  may  have  overlooked,  it  is  his  duty  to  impart  his 
discovery  to  the  surgeon,  and  it  is  also  his  duty  to  impart  it 
without  attracting  the  patient's  notice.  It  is  in  bad  taste  for 
an  assistant  to  seek  recognition  of  his  acumen.  The  credit 
belongs  to  the  surgeon;  just  as  the  assistant  is  responsible 
to  the  surgeon  and  the  surgeon  is  responsible  for  his  assist- 
ant. If  the  patient  learns  through  another  that  the  assistant 
has  made  a  shrewd  and  useful  observation,  he  will  think  ' 
the  more  of  it  because  it  was  not  immodestly  proclaimed. 
In  any  event,  it  is  bad  to  discuss  the  patient's  condition  in  his 
presence,  and  bad  to  indulge  in  loud  talking,  peremptory 
orders,  or  unnecessary  questions. 

A  patient  often  seizes  an  opportunity  to  learn  from  the  / 
assistant  some  facts  concerning  his  condition  that  the  sur- 
geon or  the  family  physician  may  not  have  imparted.  At  such  / 
a  time  if  the  assistant  hesitates  or  stammers,  he  confirms, 
perhaps,  a  fear  that  no  mere  statements  can  remove.  He 
may  answer,  often  truthfully :  "  I  have  been  too  busy  helping 
Dr. to  observe  all  the  conditions,"  or  "  I  am  not  suffi- 
ciently familiar  with  all  the  facts  to  form  any  opinion,  but 
you  may  rely  on  what  the  doctor  has  told  you." 

It  is  obvious  from  these  general  remarks  that  an  assistant's 
conduct  may  do  much  to  mar,  and  not  a  little  to  preserve,  the  / 
surgeon's  reputation  as  well  as  his  own,  and  that  if  he 
endeavors  to  conserve  the  one  he  will  go  far  towards  increas- 
ing the  other.  It  is  but  a  corollary  to  this  that  mere  manual 
dexterity  is  of  little  value  in  an  assistant  without  tact  and  dis- 
cretion, and  that  lacking  these  qualities  he  is  not  apt  to  find 
his  services  in  great  demand. 


CHAPTER   II. 
THE  HOSPITAL  INTERNE. 

The  young  surgeon's  resident  hospital  service  is  the  most 
instructive,  ought  to  be  the  most  pleasant,  and  often  proves 
the  most  important,  period  in  his  professional  career.  His 
bearing  and  his  accomplishments  during  this  term  of  "  ap- 
prenticeship "  profoundly  influence  and  may  quite  deter- 
mine his  entire  future. 

The  chief  attractions  in  medicine  are  its  intense  human 
interest  and  the  extent  to  which  it  draws  upon  all  the  arts 
and  sciences ;  and  no  time  is  better  adapted  than  his  hospital 
service  for  a  physician  to  develop  both  sides  of  his  profes- 
sion— the  philanthropic  and  the  scientific.  Zeal,  thorough- 
ness and  sincerity ;  cheerfulness,  willingness  and  punctuality ; 
forethought,  breadth  and  direction ;  courage,  caution  and 
kindness — all  these,  and  more,  are  expected  of  the  members 
of  a  hospital  staff. 

A  due  appreciation  of  these  considerations  at  the  outset 
will  properly  direct  the  interne's  work  and  govern  his  deal- 
ings with  his  colleagues,  superior  officers,  subordinates  and 
patients.  In  all  large  hospitals  there  must  be  among  the 
medical  and  nursing  corps  strict  discipline  in  the  division  of 
authority  and  responsibility.  The  junior  internes  owe 
prompt  and  cheerful  obedience  to  the  resident  surgeon 
(house  surgeon),  who  in  turn  is  directly  subordinate  to  the 
visiting  surgeon. 

Upon  the  house  surgeon  falls  the  responsibility  for  the 
details  of  treatment  and  nursing  of  the  patients,  the  complete 
records  of  all  cases,  the  proper  conduct  of  the  wards  and 
operating  rooms,  the  economical  use  of  hospital  supplies  and 
the  division  of  duties  among  the  members  of  his  staff.  The 
esprit  de  corps  of  his  assistants  will  depend  chiefly  upon 

33 


The  Resident  Staff.  33 

himself;  on  the  other  hand,  to  the  extent  that  the  junior 
internes  and  nurses  are  loyal  to  the  house  surgeon  will  he, 
in  turn,  be  inclined  to  shield  them  from  criticism. 

The  relations  between  the  juniors  and  the  visiting-  surgeon 
are  indirect.  The  house  surgeon  is  the  intermediary ;  and, 
during  rounds  and  operations  especially,  all  reports  and,  in 
a  whisper,  all  questions  and  suggestions  should  be  addressed 
to  him.  It  is  to  the  best  interest  of  the  patients  that  the  bear- 
ing of  the  house-staff  in  the  wards  should  at  all  times  indicate 
respect  for  the  surgeon  in  charge.  Even  among  themselves 
it  is,  to  say  the  least,  in  bad  taste  for  young  hospital  men  to 
ridicule  the  judgment  of  their  seniors,  from  whom  those 
young  men  have  learned  whatever  they  may  know.  Mistakes 
are  made  by  all;  and  an  experienced  man  often  has  better 
reasons  for  being  wrong  than  an  inexperienced  one  may  have 
for  being  right. 

Aside  from  the  strictly  surgical  manipulations  the  per- 
formance of  most  of  the  details  of  treatment  devolves  upon 
the  nurses.  Among  their  corps  the  same  division  of  author- 
ity obtains  as  among  the  medical  attendants.  The  head 
nurse  in  each  ward  is  directly  responsible  for  the  work  of 
her  assistants  to  the  house  surgeon,  and  all  his  directions  for 
nursing  should  be  given  to  her,  A  woman,  occupying,  while 
on  duty,  a  subordinate  position, — it  is  only  fair  to  her  that  the 
interne  should  exercise  considerate  regard  for  her  physical 
limitations  and  her  natural  sensibility,  both  in  the  character 
of  his  orders  and  in  the  manner  in  which  he  delivers  them, 
A  nurse's  education  in  medicine  is  very  elementary  and  much 
that  the  physician  does  is  more  or  less  mystifying  to  her.  If 
the  interne  will  explain  to  her  the  rationale  of  his  procedures, 
he  will  at  the  same  time  arouse  her  interest  in  the  results  and 
engage  her  more  intelligent  co-operation  in  securing  them. 
Moreover,  pupil  nurses  are  in  the  hospital  for  the  same  pur- 
pose as  are  the  internes, — to  acquire  at  the  bedside  what 
cannot  be  learned  from  text-books  and  lectures.  Naturally, 
therefore,  the  nurses  look  to  the  resident  staff  for  instruction. 

Indeed,  however  it  may  be  conducted,  every  hospital  is  a 
school  of  medicine  for  all  concerned  in  the  care  and  observa- 


34  The  Surgical  Assistant. 

tion  of  its  patients,  from  the  surgeon-in-chief  down  to  the 
probationary  nurses, — and,  indirectly,  for  the  medical  and 
nursing  world  at  large.  Even  an  ignorant  patient  under- 
stands this,  and  he  thinks  the  more  of  the  interne  who 
exhibits  a  scientific  zeal  in  the  study  of  his  ailment.  But  the 
interne  has  deservedly  lost  all  the  patient's  regard  when  he 
allows  the  scientific  to  absorb  or  obscure  the  human  side  of 
his  work — when,  in  other  words,  he  loses  sight  of  the  patient 
in  the  case!  The  patient  should  be  made  to  feel,  that  above 
all  other  interests  in  him,  the  doctors  are  most  concerned  in 
his  comfort  and  his  recovery.  Certainly  it  is  a  breach  of 
professional  relations  and,  no  less,  of  all  sympathetic  regard, 
to  declare  in  a  patient's  hearing  that,  for  example,  the  dis- 
tressing pulsations  of  a  large  aneurism  are  "  very  pretty." 
But  more  than  that,  sick  men  try  to  read  their  fate  in  the 
countenances  and  gestures  of  their  medical  attendants  and  a 
shrug  of  the  shoulders  on  the  part  of  one  of  them  may  blast 
some  poor  fellow's  hopes  of  recovery. 

The  hospital  accepts  a  sacred  trust  from  every  sufferer  it 
receives,  and  in  this  trust  each  interne  has  a  share.  He 
owes  to  the  humblest  charity  patient  no  less  than  to  the  occu- 
pant of  the  best  private  room,  unceasing  watchfulness  and 
attention,  gentleness  and  sympathy.  Not  even  the  rush  and 
hurry  of  an  active  surgical  service  excuse  prolonged  or 
repeated  examinations  when  a  patient  is  sleepy  or  in  pain, 
nor  dressings  during  the  meal  hour.  A  change  of  dressings 
may  be  either  a  trying  ordeal  or  a  source  of  much  relief  to 
the  patient,  and  in  either  event  it  should  be  conducted  at  a 
suitable  time,  gently,  thoroughly  and  with  all  surgical  clean- 
liness. Healing  is  hastened  and  comfort  is  secured  by  keep- 
ing the  neighborhood  of  the  wound  free  of  germ-harboring 
crusts,  epithelial  scales  and  dried  blood. 

History-taking  is  to  be  conducted  with  the  same  thorough- 
ness and  consideration.  A  time  should  be  selected,  if  possi- 
ble, when  the  patient  is  not  in  great  pain  nor  drowsy.  A 
sleepy  or  suffering  patient  does  not  furnish  a  very  satisfac- 
tory anamnesis  nor  does  a  patient  who  becomes  restless  or 
ill-humored  under  prolonged  questioning.     Often  an  event 


History  Taking.  35 

or  a  symptom  which  the  patient  deems  too  insignificant  to 
relate  is  of  the  utmost  importance.  The  house  surgeon 
should  therefore  select  for  history-taking  those  internes  who 
have  served  sufficiently  long  to  be  skilful  in  questioning  and 
experienced  in  etiology  and  symptomatology.  The  histories 
of  patients  too  ill  to  question  should  be  secured  as  soon  as 
possible  from  an  intelligent  near  relative. 

Following  a  record  of  the  patient's  name,  age,  sex  and 
birthplace  is  entered  on  the  first  bedside  sheet  the  family 
history.  This  consists  in  a  statement  of  hereditary  family 
tendencies  and  similar  relevant  data.  Then  follows  the 
previous  history  which  should  include  [the  manner  of  birth], 
diseases  of  childhood,  subsequent  ailments  and  injuries,  resi- 
dence in  tropical  countries,  etc.,  venereal  infections,  alcohol 
and  tobacco  habits,  etc.  The  present  history  is  ordinarily 
started  with  the  observation  of  the  first  symptom  directly 
related  to  the  patient's  ailment.  Both  the  previous  and  pres- 
ent histories  are  very  important  and  it  requires  much  careful 
questioning  to  elicit  all  the  facts  and  much  patience  to  secure 
a  record  of  symptoms  in  their  proper  order.  The  present 
history  is  to  be  summarized  with,  a  brief  statement  of  the 
patient's  chief  complaints  at  the  time. 

Following  these,  there  is  entered  the  status  praesens — a 
physical  examination  of  the  patient  as  dictated  by  the  house 
surgeon  or  visiting  surgeon  on  rounds.  The  habit  of  making 
complete  examinations  in  all  cases — ^^-even  of  patients  with  no 
other  ailment  than  hemorrhoids  or  a  hernia,  will  prove  a 
vastly  instructive  one. 

The  subsequent  history  consists  of  a  careful  record  of 
observations,  which  should  be  entered  at  the  time  they  are 
made.  Many  observations  not  important  to  the  individual 
case  are  still  noteworthy  in  that  they  may  form  the  basis  of 
important  statistical  studies  in  other  directions.  The  reports 
of  all  laboratory  examinations  should  be  duly  copied  in,  or 
otherwise  incorporated  with,  the  history,  and  photographs 
or  skiagraphs  are  mounted  on  cardboard  of  the  same  size  as 
the  bedside  sheets,  to  be  bound  with  them.  Operations  are 
to  be  described  in  the  record  within  a  few  hours  after  they 


36  The  Surgical  Assistant. 

are  performed.  Details  are  important — thus  a  statement  of 
the  number,  character  and  location  of  non-absorbable  sutures 
should  always  be  made.  A  sketch  may  greatly  illuminate  the 
description.  The  record  of  the  narcosis  is  to  be  included. 
As  each  patient  is  discharged,  or  dies,  his  history  is  to  be 
turned  over  to  the  interne  in  charge  of  it.  The  final  notes 
are  then  entered,  e.  g.,  a  reference  to,  or  copy  of,  the  autopsy 
report,  and  the  record  is  indexed  by  the  patient's  name  and 
cross-indexed  by  diseases  and  filed  away  for  binding. 

The  interne  should  make  a  point  of  accompanying  the 
house  surgeon  upon  the  rounds  of  the  visiting  surgeon,  fo<- 
it  affords  him  an  opportunity  to  learn  methods  of  diag- 
nosis. For  these  rounds  the  patients'  records  and  various 
reports  should  be  ready  for  presentation  by  the  house  sur- 
geon. By  gestures  or  whispers  the  junior  may  correct  mis- 
statements of  the  house  surgeon  but,  obviously,  he  should 
never  contradict  him  aloud.  Fresh  dressings  and  sterile 
instruments  are  also  to  be  ready  for  the  visiting  surgeon, 
and  one,  at  least,  of  the  internes  should  also  be  "  washed  up  " 
to  assist  him. 

The  house-stafif  rounds  are  likewise  important  to  the  junior 
for  they  allow  him  to  observe  symptoms  that  have  been  noted 
by  his  colleagues,  and  to  discuss  diagnosis  and  methods. 
Less  restrained  than  the  rounds  of  the  visiting  surgeon,  they 
are  none  the  less  serious,  and  they  should  never  be  allowed 
to  degenerate  by  inattention,  flirtations  or  frivolity. 


CHAPTER   III. 

ASSISTANCE  IN  EXAMINATIONS  AND  DRESSINGS. 

The  proper  disposition  of  the  assistant's  hands  and  body, 
so  essential  to  good  technics  during  operations — in  connec- 
tion with  which  subject  it  can  be  discussed  more  at  length 


Fig.  1.    Manner  of  holding  a  child  firmly  in  the  sitting  posture. 

— is  not  less  important  during  the  conduct  of  examinations 
and  dressings.  It  is,  indeed,  more  difficult  to  handle  the 
conscious  than  the  anesthetized  subject,  since  in  the  former 

37 


38 


The  Surgical  AssistAisrT. 


case  the  patient's  comfort  must  be  conserved  as  well  as  the 
surgeon's  convenience. 

For  restraining  struggling  children,  the  illustrations  here 
given  afford  suggestions.  Figure  i  illustrates  a  very  useful 
method  and  indicates  the  general  principles  involved.  The 
position  is  intended  chiefly  for  manipulations  about  the  face, 
throat  and  neck.  To  restrain  the  child's  arms  a  sheet  wound 
tightly  about  its  body  may  be  substituted  for  one  of  the 
assistant's  hands,  which  is  then  left  free  for  holding  a  mouth- 


FlG.  2.    Manner  of  holding  a  child  upon  a  table. 

gag  or  for  other  service.  Figure  2  suggests  the  manner  of 
restraining  children  upon  a  table.  Here  the  assistant  stands 
opposite  the  surgeon ;  his  arm  and  forearm  on  the  side  next 
to  the  table  are  thrown  over  the  child's  lower  extremities 
and  the  corresponding  hand  grasps  the  hands  of  the  patient; 
with  the  other  hand  the  forehead  is  held  firmly  and  the  child's 
head  is  turned  in  the  direction  required. 


Assistance  in  Examinations. 


39 


When  it  is  necessary  to  hold  a  child  high,  as  for  examina- 
tion of  the  throat  by  the  Hght  from  a  chandeher,  it  will  often 
be  found  useful  for  the  assistant   (or  parent)   to  turn  the 


Fig.  3.    Proper  manner  of  holding  foot  during  application  of  bandage. 


patient  so  that  its  head  faces  over  his  left  shoulder.  The 
assistant's  left  forearm  then  supports  the  child's  buttocks 
and,  with  the  corresponding  hand,  encircles  its  wrists  and 
thighs,  while  the  right  hand  grasps  the  occiput.  If  the  child 
is  unruly  it  would  be  well  to  further  restrain  the  lower 
extremities  by  wrapping  them  in  a  sheet  or  towel.  For  many 
manipulations  about  the  head,  e.  g.,  galvano-puncture  of  nevi, 
the  surgeon  is  often  required  to  grip  it  between  his  thighs. 
The  assistant,  seated  opposite,  then  holds  the  child's  lower 
extremities  in  a  similar  manner  in  his  own  lap,  seizing  the 
child's  wrists  with  one  hand,  and,  with  the  other,  manipulat- 
ing the  sponge  electrode. 

■  During  the  application  of  dressings,  especially  immobi- 
lizing dressings,  it  is  important  to  maintain  the  part  in  the 


40     .  The  Surgical  Assistant, 

proper  position  Avith  the  least  obstruction  by  the  assistant's 
hands.  A  single  illustration  will  suggest  the  proper  methods. 
During  the  application  of  a  dressing  to  the  leg,  one  or  two 
fingers  under  the  heel  will  amply  support  the  extremity ;  the 
other  hand  grasping  the  toes,  steadies  the  limb  and  main- 
tains the  proper  flexion  of  the  foot,  and  the  assistant's  arms 
and  body  are  disposed  so  as  to  oflfer  the  least  interference 
with  the  surgeon's  movements.  Unless  otherwise  indicated 
the  foot  should  be  flexed  to,  or  beyond,  a  right  angle,  and 
if  the  dressing  applied  is  of  plaster,  starch  or  other  firm 
material,  the  foot  should  also  be  held  inverted  until  the 
application  is  dry.  When  the  assistant  cannot  spare  a  hand 
to  maintain  flexion  of  the  foot  this  can  be  accomplished  by  the 
patient  himself  drawing  upon  each  end  of  a  long  strip  of 
bandage  passed  about  the  toes  or  beneath  the  ball  of  the  foot. 

FRACTURES   AND   DISLOCATIONS. 

The  assistant's  work  in  the  treatment  of  fractures  and 
dislocations  consists  in  counter-traction  during  the  manipula- 
tions of  reduction ;  and  in  the  maintaining  of  the  reduction, 
or  in  application  of  the  dressing  while  the  surgeon  holds  the 
joint  surfaces  or  the  bone  fragments  in  the  desired  position. 

Of  the  method  of  exerting  counter-traction  little  need  be 
said  here,  since  in  each  case  it  must  be  suggested  and  gov- 
erned by  the  manner  and  direction  of  the  traction.  It  is 
important,  however,  that  the  assistant  should  so  dispose  his 
hands  and  body,  that  while  he  does  not  impede,  by  either,  the 
movements  of  the  surgeon,  he  is  able  to  grasp  firmly  and  to 
exert  a  steady  pull  without  slipping  of  the  fingers  and  with- 
out cramping  of  the  muscles  of  his  arms  or  hands.  Gripping 
between  the  fingers  and  the  palm  is  often  firmer  and  less 
tiring  than  gripping  between  the  thumb  and  fingers.  Fig.  4 
illustrates  the  application  of  these  principles  in  exerting  trac- 
tion and  counter-traction  for  reduction  of  a  forearm  fracture. 

When  the  surgeon,  often  after  tedious  manipulation,  has 
secured  the  proper  reduction  of  the  fragments  of  a  fractured 
bone  and  has  assured  himself,  so  far  as  he  can,  that  he  has 
freed  the  ends  of  fragments  of  soft  tissue,  he  may  deem  it 


Assistance  in  Fracture  Dressings. 


41 


unwise  to  remove  his  fingers  until  the  reduction  has  been 
secured  by  a  dressing,  the  application  of  which  will  then  fall 
to  the  assistant.  Therefore,  while  the  dressing  of  fractures 
belongs  rather  to  a  work  on  surgery,  a  few  words  about  the 
materials  used  and  their  method  of  application  will  not  be 
out  of  place  here. 


Fig.  4.      Maintaining  reduction  of  forearm  fracture, 
assistant's  fingers,  arms  and  body. 


Note  position  of 


Padding. — Padding  used  for  the  prevention  of  pressure 
sores  is  most  often  of  common  or  absorbent  cotton.  When 
needed,  it  should  be  applied  freely  over  all  projecting  points, 
e.  g.,  the  iliac  spines,  the  malleoli,  the  heels  (as  in  using 
Buck's  extension  apparatus).  For  padding  the  axillae  and 
the  mammse  in  the  use  of  any  dressing  that  is  to  remain 
longer  than  a  few  days  soft  gauze,  smoothly  applied,  is 
preferable  to  cotton,  for  the  latter  soon  becomes  matted  and 
stiff  by  absorption  of  a  sour-smelling,  acrid  secretion,  and 
thus  favors  the  production  of  the  dermatitis  it  is  intended  to 
prevent. 

Before  applying  protective  padding  in  the  axillae  or  under 
the  breasts,  the  parts  should  be  washed  with  soap  and  water 


42 


The  Surgical  Assistant. 


and  then  with  alcohol,  then  dried  carefully  and  dusted  over 
evenly  and  freely,  but  not  too  thickly,  with  starch  or  talcum 
powder. 

Pads  that  are  intended  to  exert,  rather  than  to  prevent, 
pressure  should  be  made  of  gauze,  folded  into  a  sufficient 
thickness  and  trimmed  to  the  exact  size  required.  They 
may  be  fastened  to  the  skin  or  to  the  splint  by  strips  of 
adhesive  plaster,  or  allowed  to  hold  their  proper  position  by 
the  pressure  of  the  dressing  alone. 


Fig.  5.    Triangular  cardboard  axillary  pad. 


Triangular  axillary  pads,  such  as  are  needed  in  the  dress- 
ing of  fractures  of  the  humerus,  may  be  quickly  fashioned 
from  heavy  manilla  cardboard.  This  is  cut  the  width  of  the 
axilla,  and  bent  into  triangular  shape,  the  ends  being  secured 
by  strips  of  adhesive  plaster.  The  pad  is  covered  smoothly 
>vith  gauze  ^nd  held  in  place  with  adhesive  strips  passing 


Preparation  of  Splints.  43 

over  the  opposite  shoulder.    Triangular  pads  may  be  simi- 
larly fashioned  for  the  popliteal  space  or  the  elbow. 

Splints. — Two  kinds  of  wood  lend  themselves  most  readily 
to  the  fashioning  of  flat  splints — thin  pine,  and  cigar-box 
wood.  Of  the  latter,  two  or  more  thicknesses  are  usually 
needed.  Such  splints  should  be  cut  to  appropriate  length 
and  breadth,  and  should,  ordinarily,  have  rounded  ends. 
Cigar-box  wood  is  very  readily  trimmed  to  proper  size  and 
shape  with  a  pocket-knife  or  with  bandage  scissors,  and, 
although  it  splits  easily,  there  is  but  little  difficulty  in  cutting 
it  to  fit  rounded  parts,  e.  g.,  the  thenar  eminence.     Gauze, 


Fig.  6.    Padded  straight  splint. 

folded  smoothly  in  several  thicknesses,  is  the  best  padding. 
It  should  be  long  enough  to  prevent  contact  between  the  skin 
and  the  edges  of  the  splint,  and  may  be  fastened  to  the  latter 
with  a  bandage  or,  more  elegantly,  with  adhesive  strips. 

Cigar-box  wood  may  be  readily  molded  to  a  curved  sur- 
face (e.  g.,  the  arm)  in  the  following  manner.  The  splint  is 
laid  upon  the  face  of  a  piece  of  adhesive  plaster  of  the  same 
size.  Then,  with  a  knife,  parallel  slits  are  cut  longitudinally 
through  the  wood  and  down  to,  but  not  into,  the  adhesive 
plaster.  In  this  way,  a  firm,  transversely  flexible  form  is 
made,  hinged  upon  the  plaster  and  capable  of  being  molded 
to  the  extremity.  The  greater  the  curve  of  the  surface  to 
which  such  a  splint  is  to  be  applied  the  narrower  should  be 
made  the  strips  into  which  the  splint  is  divided. 

Basswood  veneering  is  a  most  useful  material  for  rein- 
forcing immobilizing  dressings  and,  with  starch  dressings 
especially,  affords  an  elegant,  light,  but  strong  and  durable 
splinting.  It  is  readily  torn  into  strips  and  being  very  flex- 
ible, can  be  applied  lengthwise,  spirally  or  circumferentially. 
Its  flexibility  may  be  increased  by  soaking  it  a  few  minutes 


44  The  Surgical  Assistant. 

in  warm  water.  In  applying  a  starch  dressing  over  the  leg 
and  foot  the  veneer  strip  run  anteriorly  may  be  split  into 
several  pieces  over  the  dorsum  pedis  and  there  spread  out 
like  a  fan.  When  used  for  immobilizing  the  knee  or  ankle 
in  a  dressing  not  absolutely  rigid,  it  must  be  remembered  that 
thin  strips  of  veneering  will  be  apt  to  crack  in  the  popliteal 
space  or  in  front  of  the  ankle.  At  such  levels,  therefore,  they 
should  be  made  to  pass  to  the  sides  of  the  joints  or  should  be 
reinforced  by  some  heavier  material. 

Reinforcing  strips  are  most  useful  when  incorporated  in 
the  bandage,  rather  than  under  it.  Thus  veneering  strips 
may  be  introduced  during  the  application  of  the  starch  band- 
ages— a  turn  or  more  of  the  bandage  between  the  strips. 

Tin  Strips  are  very  useful  for  reinforcing  plaster  dress- 
ings. When  not  too  heavy  they  may  be  curved  about  flexed 
joints,  but  the  assistant  must  be  very  careful  to  see  that  the 
surface,  and  not  the  edge  of  the  strip,  is  at  all  points  flat 
against  the  dressing.  Perforating  the  strips  with  an  awl 
makes  them  less  liable  to  slip  in  the  plaster.  The  holes  should 
be  punched  at  frequent  intervals  and  alternately  inward  and 
outward,  so  that  the  rough-edged  awl-hole  can  afford  a 
better  "  grip  "  for  the  plaster.  It  must  be  borne  in  mind 
that  metal  strips,  unless  very  narrow  and  used  sparingly, 
greatly  interfere  with  the  x-ray  examination  of  the  parts  so 
important  after  dressing  a  fracture. 

Heavy  cardboard  splints,  used  in  immobilizing  the  elbow, 
etc.,  should  be  fashioned  by  tearing,  not  by  cutting,  for  torn 
edges  are  thin  and  readily  molded  to  a  curved  surface.  At 
the  angle  corresponding  to  the  joint  the  molding  is  facilitated 
by  one  or  two  incomplete  transverse  tears.  Moistening  the 
splints  in  water  adds  to  their  flexibility. 

Starch  (Dextrin)  Crinolin  Bandages  are  to  be  softened 
in  warm  water,  squeezed  out,  and  freed  of  loose  strands, 
before  applying.  They  shrink  markedly  in  width  when 
moistened  and  therefore  even  for  finger  dressings  the  assist- 
ant should  not  select  one  narrower  than  one  and  a  half  or 
even  two  inches.  Starch  bandages  applied  too  thickly  will 
be  found  to  dry  only  in  the  outer  layers,  the  deeper  ones 


Assistance  in  Immobilizing  Dressings. 


45 


remaining  moist  for  many  days.  They  should  not  be  applied 
next  to  the  skin,  nor  directly  over  absorbent  cotton.  In 
addition  to  their  use  for  immobilizing,  a  few  turns  of  a  starch 
bandage  serve  admirably  to  prevent  an  ordinary  dressing 
from  slipping,  as  from  the  finger  or  the  head.  The  stiff 
starch  bandage  may  easily  be  removed  by  cutting  it  through 
with  a  pocket  knife  or  by  moistening  and  unrolling  it. 

Plaster  of  Paris. — Ample  protection  to  the  patient's  cloth- 
ing, furniture  and  floor  should  be  secured  by  means  of  linen 
or  rubber  sheets.  The  assistant  will  do  well  to  cover  also 
his  own  shoes  and  clothing. 

After  cleansing  the  patient's  skin  and  dusting  it  with  tal- 
cum powder,  flannel  bandages  should  be  applied  smoothly 


Fig.  7.    Plaster  dressing— arrangement  for  making  soft  cuff. 


over  the  part,  extending  two  or  more  inches  beyond  what  are 
to  be  the  edges  of  the  plaster  dressing.    Over  the  flannel  is 


46 


The  Surgical  Assistant. 


smoothly  laid  absorbent  or,  better,  non-absorbent  cotton, — 
over  projecting  parts  or  on  the  entire  surface  or  in  a  ring  at 
the  ends  of  the  dressing.  The  cotton  extends  only  to  within 
about  two  inches  from  the  ends  of  the  flannel,  but  a  little  be- 
yond the  levels  where  the  plaster  dressing  will  stop.  On  many 
parts  of  the  body,  e.  g.,  the  lower  extremity,  hip  and  chest,  a 
white  stocking  or  circular  stockinet  or  a  section  of  balbriggan 
underwear,  may  be  applied  smoothly  next  to  the  skin,  instead 
of  the  flannel  bandages. 

To  prevent  the  plaster  from  adhering  to  his  hands  the 
assistant  may  now  anoint  them  with  vaselin  (especially 
about  the  finger  nails)  or,  better,  cover  them  with  rubber 
gloves,  or  with  Murphy's  gutta-percha  solution  (page  yj). 


7   f\   -r 

Fig.  8.    Freeing  bandage  of  frayed  edges. 


Plaster  of  Paris  bandages  should  be  very  loosely  rolled  and 
the  powdered  plaster  should  be  evenly  and  smoothly  distrib- 
uted in  the  meshes  of  the  crinolin.     They  must  be  kept  in 


Plaster  of  Paris. 


47 


air-tight  containers,  e.  g.,  tin  canisters  sealed  with  adhesive 
plaster.  One  by  one,  as  needed,  the  bandages  are  submerged 
in  a  basin  of  lukewarm  water  and  held  there  until  they  cease 
to  give  off  bubbles.  It  is  essential  to  cover  the  entire  bandage 
at  once  with  the  water,  and  it  is  best  to  use  a  basin  deep 
enough  to  submerge  the  bandage  end  up.  A  little  salt  added 
to  the  water  hastens  the  setting  process,  but  tends  to  make 
the  finished  dressing  less  firm.  It  is  unnecessary,  since  good 
plaster  sets  quickly.  When  the  bubbling  has  ceased,  the 
assistant  lifts  the  bandage  from  the  water  and,  still  holding 
it  over  the  basin,  gently  squeezes  it.  Each  edge  is  to  be 
quickly  freed  of  all  loose  threads.  The  beginning  of  the 
bandage  is  then  found  and  opened  out  a  few  inches.     With 


Fig.  9.    Handing  plaster  bandage. 


this  part  held  in  his  right  hand  and  the  body  of  the  roller, 
facing  upward,  in  his  left,  the  assistant  places  the  bandage  in 
the  hands  of  the  operator  in  such  a  manner  that  it  can,  thus, 


48  The  Surgical  Assistant. 

be  applied  to  the  dressing.  If  the  operator  is  left-handed  the 
assistant  reverses  the  position  of  the  bandage,  keeping  the 
roller  upward. 

If  the  assistant  is  called  upon  to  apply  the  bandage  himself 
he  must  be  careful  to  exercise  no  pressure,  but  to  allow  the 
roller  to  pass  about  the  part  with  scarcely  greater  tension 
than  its  own  weight.*  During  their  application  both  operator 
and  assistant  should  continuously  smooth  out  the  plaster 
bandages  with  the  fingers  and  the  palms  of  the  hands.  This 
is  to  be  done  rapidly  and  always  in  the  same  direction  (that 
in  which  the  turns  are  made)  to  keep  the  edges  of  the 
bandages  flat.  If  the  bandages  are  "  thin  "  this  smoothing 
process  may  be  used  to  incorporate  a  little  extra  plaster  paste, 
scooped  from  the  bottom  of  the  basin  in  which  the  bandages 
are  wet,  or  made  in  the  palm  of  the  hand  from  dry  plaster 
powder  and  water.  If  it  is  found  that  a  bandage  has  begun 
to  set  before  all  of  the  roller  is  applied,  the  assistant  should 
cut  off  the  unused  part  and  prepare  a  fresh  bandage. 
Between  turns  of  the  dressing  reinforcing  splints  of  tin, 
wood,  etc.,  may  be  incorporated.  The  plaster  bandages 
themselves  may  be  used  to  reinforce  special  parts,  e.  g.,  the 
ankle,  sole  of  the  foot,  groin,  etc.,  by  passing  them  back- 
wards and  forwards  several  times  over  these  points. 

Before  the  last  bandages  are  applied  near  the  edges,  the 
projecting  flannel  is  turned  down  over  the  cotton  and  the 
plaster,  and  is  then  held  in  place  with  a  few  turns  of  the 
plaster  bandage.  Thus  are  formed  neat,  soft,  even  cuffs. 
A  plaster,  starch,  or  other  dressing  applied  over  the  groins 
of  children  or  feeble  adults  may  be  protected  from  soiling 
with  urine,  by  incorporating  in  it  a  large  piece  of  rubber 
tissue  turned  over  the  edge  and  covered  by  the  last  turns  of 
the  dressing.  The  smoothing  process  should  be  continued 
for  several  minutes  after  all  the  bandages  have  been  put  on, 
until  the  dressing  is  even  and  of  graceful  contour,  and  the 
edges  and  meshes  of  the  bandages  are  lost  to  view.    Plaster 

*  There  is  some  discussion  as  to  whether  or  not  plaster  contracts 
in  setting.  Be  that  as  it  may,  if  the  bandage  is  applied  more  tightly 
than  above  described  the  cast  will  be  too  tight. 


Plaster  of  Paris. 


49 


is  heavy  at  best,  and  the  assistant  should  therefore  make  the 
dressing  no  thicker  than  it  has  to  be.  The  final  smoothing 
requires  but  a  very  thin  paste  or  no  paste  at  all. 

The  assistant  should  see  that  the  patient  maintains  the 
proper  position  from  the  beginning  of  the  dressing  until  the 
plaster  is  dry.  Applied  to  the  leg  only,  the  heel  may  be 
supported  upon  a  high  cushion  or  a  chair.  Applied  as  a 
hip-spica,  or  about  the  trunk,  a  hip-rest  must  be  used  if  the 
patient  is  recumbent.    Applied  to  the  leg  and  foot,  it  is  essen- 


Fig.  10.      Plaster  dressing— smooth  cuff  formed.    Dotted  rectangular  line 
about  genitals  indicates  sheet  of  gutta-percha. 


tial  that  the  latter  should,  in  most  cases,  be  held  inverted  and 
at  right  angles.  If  no  assistant  can  be  spared  to  grasp  the 
toes  for  this  purpose,  the  position  may  be  secured,  as 
described  before,  by  passing  a  gauze  bandage  under  the  ball 
of  the  foot  and  placing  its  ends  like  a  pair  of  reins,  into  the 
hands  of  the  patient.     Finally,  before  the  assistant  leaves 


60  The  Surgical  Assistant. 

the  patient  he  should  make  sure  that  the  dressing  is  not 
tight  enough  to  impede  the  circulation  in  the  part.  In  dis- 
pensary and  hospital  practice  it  is  convenient  to  mark  upon 
fracture  dressings,  in  ink,  the  date  of  their  application. 

As  soon  as  possible  all  open  but  unused  cans  of  plaster 
or  plaster  bandages  should  be  tightly  closed  and  sealed  with 
a  strip  of  adhesive  plaster  over  the  overlapping  edge  of  the 
cover. 

The  preliminary  cleansing  of  the  hands  of  plaster  should 
not  be  performed  in  a  plumbed  basin,  but  in  a  portable  one 
for  otherwise  the  drain  or  trap  may  be  occluded.  Rubbing 
with  granulated  sugar  aids  somewhat  in  removing  plaster 
from  the  hands,  as  does  also  the  addition  of  a  tablespoonful 
of  sodium  carbonate  to  the  water  in  which  they  are  washed. 

The  removal  of  a  plaster  dressing  requires  as  much 
patience  as  skill.  An  excellent  tool  for  the  purpose  is  a  car- 
penter's miter  saw.  Also  useful,  but  less  satisfactory,  is  a 
well  pointed  pruning  knife.  The  track  through  which  the 
knife  is  to  pass  may  be  softened  by  means  of  strong  acetic 
acid  applied  from  time  to  time  with  a  brush  or  a  dropper. 
Heavy  plaster  shears  are  of  use  only  when  the  dressing  is  of 
little  thickness.  As  in  the  application  of  plaster,  so  before 
its  removal  the  patient  and  the  floor  should  be  protected 
from  soiling. 

CHANGE   OF   DRESSINGS. 

The  dressing  of  a  recent  aseptic  wound  requires  the  same 
preparations  on  a  small  scale  that  operations  do  on  a  large 
one.  For  use  in  the  dressing  of  granulating  or  suppurating 
wounds,  however,  freshly  laundried  towels  may  be  con- 
sidered surgically  clean.  They  may,  moreover,  be  rendered 
sterile  by  soaking  in  a  strong  solution  of  bichlorid  of  mer- 
cury (^  per  cent.)  or  of  carbolic  acid  (5  per  cent.)  Forceps, 
probes  and  scissors  may  be  rapidly  and  effectually  sterilized 
for  a  small  dressing  by  passing  them  through  an  alcohol  or 
Bunsen  flame.  Jeweller's  aluminum  tweezers  and  aluminum 
probes  may  be  repeatedly  sterilized  in  this  way,  but  expensive 


Assistance  in  Change  of  Dressings. 


51 


instruments  should"  be  "  boiled."  "  Wipes  "  made  of  dry 
sterile  gauze,  or  smooth  balls  of  absorbent  cotton  soaked  in 
a  sterile  solution,  make  satisfactory  sponges.  A  sufficient 
number  of  them  should  be  prepared  in  advance  and,  indeed, 
"  packings,"  pads,  lunar  caustic,  irrigating  solutions  at  proper 
temperature  and  all  else  that  will  be  needed  should  be  made 
ready  before  the  dressing  is  begun,  in  order  to  avoid  unnec- 
essary delay. 

The  patient  should  first  be  placed  in  a  comfortable  position 
and  protected  by  a  rubber  sheet,  if  necessary,  against  soiling 
of  his  body  or  bedding.  A  towel  is  slipped  under  the  part, 
pins  are  removed  from  the  dressing  and  placed  conveniently 


Fig.   11.    Arrangement  for  dressing  wound  of  the  neck.    Note  hair  gath- 
ered up  under  towel  and  head  supported  by  assistant  (nurse). 


at  hand,  e.  g.,  in  the  assistant's  coat  or  apron,  and  the 
bandage  is  cut  through  from  below  upward  and  in  a  line  not 
over  the  wound.  The  superficial  dressings  should  be  re- 
moved gently,  if  necessary  moistening  them  with  a  sterile 
solution  squeezed  from  a  sponge,  if  the  hands  are  clean,  or 
dripped  from  a  syringe. 

The  deep  dressing  should  be  left  in  place  until  sterile 
towels  are  placed  under  the  part  and  around  it.  Soiled  dress- 
ings should  be  removed  with  forceps  and  dropped  at  once 


52  The  Surgical  Assistant. 

into  a  basin  or,  better  yet,  into  a  grocer's  paper  hag.  This 
is  an  excellent  receptacle  for  discarded  dressings,  soiled 
sponges,  etc.  If  its  bottom  is  spread  out,  it  will  stand  open 
even  on  a  bed,  and  a  tear  in  its  mouth  will  facilitate  the  intro- 
duction of  gauze  and  bandages.  The  deep  dressing  should 
be  removed  with  clean  forceps  or,  if  it  is  aseptic,  with  disin- 
fected hands.  If  adherent  to  the  skin  this  dressing  should 
first  be  moistened.  Upon  withdrawing  a  packing,  the  assist- 
ant should  be  prepared  with  a  towel  or  a  pus  basin  to  receive 
a  small  or  large  amount  of  pus  or  other  discharge  that  some- 
times escapes  from  a  wound.  The  removal  of  adhesive  strips 
is  facilitated  by  pressing  under  them  a  bit  of  absorbent  cotton 
dipped  in  benzin.  Ether  is  also  excellent  for  this  purpose, 
but  it  is  irritating  to  the  wound  and  frequently  nauseates 
the  patient. 

Oftentimes  the  assistant  must  support  the  part  as  well  as 
assist  with  the  dressing  itself.  Figure  ii  illustrates  how  this 
may  be  accomplished.  Whatever  position  the  assistant  is 
called  upon  to  assume  he  must  above  all  be  careful  not  to 
embarrass  the  movements  of  the  surgeon  nor  to  obstruct  the 
passage  of  light  to  the  wound. 


CHAPTER   IV. 

PREPARATIONS  FOR  AN  OPERATION. 

THE    ROOM. 

The  preparation  of  a  room  for  operation  naturally  falls 
to  an  assistant,  either  a  physician  or  a  nurse.  If  left  to 
the  latter  it  is  still  the  duty  of  the  assistant  surgeon  to 
overlook  the  work  done  and  to  see  that  all  details  have  been 
provided  for  before  the  operation  is  begun.  It  is  necessary, 
therefore,  that  he  should  have  an  orderly  system  of  prepara- 
tion and  a  knowledge  of  what  may  be  needed,  otherwise  he 
will  add  confusion  to  a  family's  distress  and,  by  the  omis- 
sion of  something  important,  invite  delay  or  disaster  in  the 
operation. 

The  comfort  of  the  family,  and  especially  of  the  patient, 
is  therefore  to  be  considered  in  the  choice  of  the  room  for 
operation,  as  well  as  are  its  size,  the  arrangement  of  the  light, 
the  proximity  of  running  water,  and  the  heating  and  venti- 
lating facilities,  etc. 

The  room  selected  should  be  large,  if  possible.  A  nursery 
has  the  advantages  that  its  preparation  usually  requires 
but  little  removal  of  furniture,  and  that  it  can  be  sacrificed 
by  the  family  for  a  few  hours  without  much  inconvenience. 
The  dining-room  is  well  adapted  to  the  purpose,  for  it  is 
often  uncarpeted,  is  usually  well-lighted,  and  being  near 
the  kitchen,  is  convenient  for  washing,  sterilizing,  the  selec- 
tion and  carrying  of  basins,  and  the  speedy  removal  of  soiled 
articles  when  the  operation  is  concluded.  The  operating 
room  should  be  near  to,  and,  if  possible,  on  the  same  floor 
as  the  patient's  bedroom.  The  latter  may  itself  be  used  for 
the  operation — -the  patient  retiring  to  another  room  during 
the  preparations.  This  arrangement  is  convenient  when  the 
patient  is  too  heavy  to  be  carried  far,  and  it  saves  him  the 

53 


64  The  Surgical  Assistant. 

exposure  of  transportation  through  a  sometimes  cold  hall- 
way. On  the  other  hand,  it  has  the  serious  drawbacks  that 
the  sickroom,  which  from  the  first  should  be  fresh  and  well- 
ventilated  is,  instead,  filled  with  fumes  of  chloroform  or 
ether,  and  littered  with  paraphernalia  that  cannot  easily  be 
removed  without  disturbing  the  invalid. 

The  room  selected,  the  assistant  should  next  see  that  there 
are  provided  those  supplies — most  of  them  obtainable  at  a 
drugstore — that  will  be  needed.     They  are : 

1.  Three  cheap,  unvarnished  hand-brushes. 

2.  Green  soap,  %  ii;  or  "  marble  soap  "  ;*  or  "  synol  "  or 
other  antiseptic  soap. 

3.  One  or  two  orange  sticks  or  new  meat  skewers,  or 
other  nail  cleaners. 

4.  One  pint  of  alcohol,  95  per  cent. 

5.  Two  or  more  five-yard  jars  of  plain  sterilized  gauze. 

6.  One  one-pound,  or  two  half-pound  cartons  of  steri- 
lized absorbent  cotton. 

7.  Bichlorid  of  mercury  tablets. 

8.  Purified  chloroform,  §  iii  ss  (original  bottle). 

9.  Two  or  more  cans  of  purified  ether,  I  iii  ss  each. 

10.  Tablets  for  hypodermatic  use,— strychnin,  nitro- 
glycerin, morphin,  atropin. 

11.  Whiskey. 

12.  "Washing  soda. 

13.  Safety  pins. 

14.  Vaselin  or  albolene  for  the  anesthetist, 

15.  Razor;  shaving  brush. 

16.  Pure  carbolic  acid,  ^  i-^  ii. 

17.  Chlorid  of  lime;  carbonate  of  soda. 

18.  One  demijohn  of  distilled  water. 

19.  One  two-quart  fountain  syringe. 

*  A  mixture  of  soap  and  marble-dust  for  removing  scales  of  epi- 
dermis. 


Preparation  of  an  Operating  Room.  55 

20.  One  yard  or  less  of  surgeon's  gutta-percha  ("  rubber 
tissue  "). 

21.  One  roll  of  adhesive  plaster  of  suitable  width. 

22.  One  five-yard  jar  of  iodoformized  gauze,  5  per  cent. 

23.  Gauze  or  muslin  bandages. 

24.  Cheese-cloth  for  a  binder.* 

25.  Rubber  tubing  for  drainage  tubes. 

26.  Oilcloth  or  rubber  sheeting  for  the  table. 

27.  Oilcloth  or  tar-paper  for  the  floor. 

Of  these  supplies  some  may  be  provided  by  the  surgeon, 
several  may  be  found  in  the  house,  and  some  or  all  of  items 
14  to  27  may  be  unnecessary.  Again,  the  tastes  of  the 
operator  or  the  needs  of  the  case  may  make  it  necessary 
to  secure  other  articles,  for  example :  crystals  of  potassium 
permanganate  and  of  oxalic  acid ;  plaster  of  Paris  bandages ; 
flannel  bandages ;  non-absorbent  cotton ;  collodion ;  sterile 
adhesive  strips ;  hydrogen  dioxid ;  lysol ;  creolin ;  boracic 
acid;  adrenalin;  cocain,  chloretone,  eucain,  or  other  local 
anesthetic ;  chemically  pure  sodium  chlorid  or  "  infusion  tab- 
lets ;  "  formaldehyd  solution,  etc. 

Gauze  commercially  sterilized  should  be  in  jars,  tubes  or 
tin  cans,  rather  than  in  pasteboard  cartons.  If  it  is  neces- 
sary to  economize  there  may  be  ordered  one  jar  for  pack- 
ings, sponges,  and  the  inside  dressing,  and  one  or  more 
cartons  for  the  outside  dressing.  It  is  desirable  then  to 
select  cartons  in  which  the  gauze  is  packed  in  layers  rather 
than  those  in  which  it  is  packed  in  a  roll,  all  of  which  latter 
must  be  lifted  out  in  order  to  cut  off  a  small  piece. 

Before  arranging  the  room  itself,  the  assistant  should 
direct  the  sterilization  of  a  sufficient  number  of  towels.  Dry 
sterilization    in   the   kitchen   oven   is   objectionable,   in   the 

*  A  towel  serves  admirably  for  children  and  slender  adults  ;  for 
stout  subjects  towels  may  be  stitched  end  to  end. 


56  The  Surgical  Assistant. 

writer's  opinion,  because  without  a  suitable  thermometer 
there  is  no  assurance  that  the  temperature  is  sufficiently 
high  unless,  as  is  often  the  case,  the  towels  are  actually 
burned.  Soaking  in  sublimate  solution,  1-500,  is  better, 
but  sterilization  by  steam  or  by  boiling  water  is  best  of 
all.  A  large  kettle  should  be  filled  with  water  and  placed 
upon  the  fire  in  the  kitchen  or,  more  conveniently,  upon  a 
gas-stove  in  or  near  the  operating  room.  A  capacious  wash- 
boiler,  if  at  hand,  is  preferable  to  the  kettle  for  it  will  accom- 
modate towels,  sheets,  basins,  hand-brushes,  fountain  syringe 
(which,  if  new,  should  first  be  rinsed  out  with  running 
water),  orange  sticks  and  a  pitcher,  and  it  will  afford,  in 
addition,  a  large  stock  of  hot,  sterilized  water. 

From  the  fund  of  towels  that  can  be  spared  for  the  opera- 
tion, six  to  twelve  should  be  laid  aside  to  use  dry.  One 
to  two  dozen,  preferably  without  fringes  and  free  from  holes, 
should  be  wrapped  up  in  one  or  two  packages,  enclosed  in  a 
towel  or  a  sheet  and  dropped  into  the  wash-boiler  or  sus- 
pended in  its  steam. 

If  the  supply  of  towels  is  small,  clean  dish-cloths  or  dis- 
carded napkins  may  be  substituted ;  or  one  bed  sheet  may 
be  used  to  take  the  place  of  many  towels.  Strips  of  bandage 
may  be  tied  by  one  end  to  a  handle  of  the  clothes-boiler, 
and  by  the  other  end  to  the  towel  packages  and  other  articles 
being  sterilized,  thus  affording  a  ready  means  of  lifting 
out  all  of  these  from  the  hot  water.  If  there  is  at  hand  no 
receptacle  large  enough  to  hold  the  basins  for  boiling,  or 
for  their  immersion  (for  fifteen  minutes)  in  yV  per  cent, 
sublimate  solution,  the  assistant,  while  busying  himself  with 
other  details,  can  direct  the  sterilization  of  the  basins  in  the 
following  manner :  Each  one  is  thoroughly  scrubbed  with 
water  and  soap,  then  scalded  with  boiling  water.  Into  one 
is  then  poured  two  or  more  ounces  of  pure  carbolic  acid 
which  is  made  to  circulate  over  the  surface.  Most  of  this  is 
then  poured  into  the  next  basin  and  the  process  repeated, 
the  excess  of  carbolic  acid  being  poured  into  the  third  basin, 
and  so  on.  To  the  carbolic  acid  remaining  in  each  receptacle 
is  then  added  enough  hot  water  to  make  a  carbolic  acid 


Preparation  of  an  Operating  Room.  57 

solution  of  about  3  per  cent,  to  5  per  cent,  strength. 
This  is  flowed  several  times  over  the  interior  and  the  edges, 
and  after  standing  a  few  minutes  is  poured  out.  The  basins 
are  then  rinsed  out  with  boiled  water.  Once  sterilized  none 
of  them  should  be  handled  by  the  rim  and,  it  need  hardly 
be  added,  dishes  not  sterilized  by  boiling  should  not  be  piled 
upon  one  another. 

Enamelled  basins  are,  of  course,  the  most  suitable,  but 
there  is  no  need  to  purchase  them,  cheap  though  they  be. 
Even  a  poorly  furnished  kitchen  will  usually  contain  all 
the  basins  needed  for  any  operation.  Kitchen  bowls,  dishes 
used  for  mixing  dough,  and  soup  tureens  answer  admirably 
for  sponge-,  and  hand-basins,  and  soup  plates  will  serve  for 
ligature  dishes,  etc.  If  instrument  trays  are  needed  and 
are  not  supplied  by  the  surgeon,  clean  baking  pans  and  plat- 
ters may  be  pressed  into  service,  but  it  will  serve  as  well  to 
spread  the  instruments  out  on  sterilized  towels.  The  follow- 
ing list  includes  all  the  basins,  trays,  etc.,  that  will  be 
needed : 

Three  hand  basins  for  sublimate  solution. 

One  hand  basin  for  alcohol. 

Tvtro  large  sponge  basins  if  sea-sponges  are  used. 

One  basin  to  contain  strong  sublimate  solution  for  liga- 
ture bottles  and  tubes,  and  gutta-percha. 

One  small  basin  for  sponge  to  cleanse  instruments. 

One  or  two  dishes  for  ligatures  and  sutures. 

One  or  two  pans  for  instruments. 

One  dish  for  soap  and  water  to  cleanse  field  of  operation. 

One  slop-jar. 

To  which  may  be  added : 

A  basin  for  hot  pads. 

A  bowl  to  receive  pus  or  other  discharge. 

A  cup  or  saucer  to  serve  as  a  specimen  dish. 

Two  basins  for  solutions  of  potassium  permanganate  and 
oxalic  acid,  respectively. 

A  dish  for  salt  solution. 


58  The  Surgical  Assistant. 

A  shaving  mug,  and 
For  the  Anesthetist : 
A  basin,  and  a  tumbler  for  boiled  water. 

Having  inaugurated  the  sterilization  of  the  towels,  dishes, 
etc.,  the  assistant  can  now  give  his  attention  to  the  arrange- 
ment of  the  room  itself.  Enough  furniture  should  be  moved 
aside  to  provide  ample  space.  It  is  unnecessary  to  clear  the 
room,  however,  and  unless  the  preparations  are  made  the 
day  preceding  the  operation,  dusting,  sweeping,  and  the  mov- 
ing of  pictures  should  be  avoided.  Sheets  may  be  spread 
over  furniture,  mantel-shelf,  and  ornaments,  but  this  is  not 
necessary.  Where  the  operating  table  is  to  stand  the  floor 
should  be  protected  with  a  piece  of  linoleum,  or  lacking 
this,  with  old  rugs,  newspapers,  tar-paper,  or  sheets,  tacked 
down. 

For  the  operating  table  the  kitchen  again  can  usually  be 
drafted  upon.  Library  tables,  too,  are  often  suitable,  and 
if  necessary  two  tables  may  be  lashed  together,  end  to  end, 
inequalities  in  their  height  being  evened  by  means  of  a 
folded  blanket  or  a  pillow.  The  weaker  table,  if  two  are 
joined,  should  be  used  for  the  patient's  head — unless  that 
is  the  part  to  be  operated  upon.  Obviously,  the  operating 
table,  if  possible,  should  be  placed  near  the  window,  when 
operating  by  daylight ;  but  it  is  more  important  that  the 
light  should  fall  into  the  wound  than  that  the  superficial 
field  of  operation  should  receive  the  greatest  amount  of 
light.  Thus,  for  a  vaginal  hysterectomy  the  patient's  head 
should  be  furthest  from  the  window,  but  for  an  abdominal 
hysterectomy  the  position  should  be  reversed. 

Over  the  table  is  spread  a  folded  blanket,  upon  this  the 
rubber  sheet,  and  over  both  a  fresh  linen  sheet.  At  the 
foot  of  the  table  is  laid  a  folded  blanket  or  sheet,  or  both, 
to  cover  the  patient.  At  the  head  is  placed  a  pillow,  prefer- 
ably flat  and  of  hair,  and  nearby  a  folded  towel.  For  an 
operation  upon  the  kidney  (q.  v.)  a  firm  cylindrical  cushion 
or  sandbag,  or  a  pillow  rolled  into  a  cylinder,  is  to  be  laid 
across  the  middle  of  the  table. 


Preparation  of  an  Operating  Room. 


59 


Beyond  the  head  of  the  table  is  placed  a  chair  for  the  anes- 
thetist and  to  one  side  of  this  a  small  table  or  another  chair, 
covered  with  a  towel,  for  the  anesthetist's  armamentarium. 


Fig.  12.  General  scheme  of  operating  room  arranged  in  private  dwelling. 
«,  a,  window  panes  (soaped)  ;  b,  oilcloth  ;  c,  operating  table  ;  d,  pillow;  e,  slop- 
'jar;/",  anesthetist's  chair;  g,  anesthetist's  table  ;  //,  operator;  /,  assistant; 
/,  nurse  ;  k,  instrument  table  ;  /,  nurse's  table  ;  ni,  m,  hand  basins  ;  n,  mantel- 
shelf with  unsterilized  accessories  ;  o,  wash-basin  ;  p,  basin  of  alcohol ;  q, 
basin  of  sublimate  solution  ;  r,  boiler  of  hot  water  ;  s,  demijohn  of  distilled 
(cold)  water  ;  /,  irrigating  bag. 

On  each  side  of  the  operating  table  and  at  a  convenient  dis- 
tance from  it  is  placed  a  chair,  stool,  or  large  wooden  box 
(which  may  also  be  covered  with  a  towel)  for  a  hand  basin. 


60 


The  Surgical  Assistant. 


A  slop-pail  is  then  placed  on  one  side  of,  and  partly  under, 
the  table.  It  is  best  located  on  the  side  where  is  to  stand 
the  assistant  who  sponges  the  wound.  On  the  opposite  side 
is  sometimes  needed  a  footstool  for  the  operator.  The  Tren- 
delenburg position  may  be  secured  by  the  familiar  method 
shown  in  the  illustration,  the  table  coverings  being  continued 
over  the  back  of  the  chair  and  the  pillow  moved  to  the 
center  of  the  table. 


Fig.  13.     Improvised  Trendelenburg  table. 

For  operations  about  the  perineum,  the  table  is  arranged 
as  shown  in  figure  14.  For  a  Kelly  pad  may  be  substituted 
the  rubber  sheet.  The  upper  end  is  tucked  about  a  twisted 
sheet  arranged  in  a  horseshoe ;  the  lower  end  drains  over 
the  end  of  the  table  into  the  slop-pail.  The  drainage  is  better 
maintained  by  pinning  together  in  front  the  two  lower  cor- 
ners of  the  sheeting,  thus  forming  a  funnel.  (The  same 
device  may  be  employed  laterally  upon  the  table  for  other 
operations.  Used  for  drainage,  it  will  be  found  economical 
to  purchase  sheeting  coated  with  rubber  on  both  sides  and 
therefore  easy  to  free  of  blood-stains.)  At  the  foot  of  the 
table  are  placed  two  chairs — one  for  the  operator  on  the  left, 
the  other  for  the  assistant  on  the  right.  The  hand  basins  and 
instrument  table  are  placed  nearby.  A  twisted  sheet  laid 
on  the  operating  table  in  the  manner  illustrated,  to  be  passed 


Preparation  of  an  Operating  Room. 


61 


from  behind  the  patient,  over  one  of  the  shoulders  and  tied 
at  the  knees,  makes  an  excellent  leg-holder.  It  may  be  sup- 
plemented by  a  piece  of  broomstick,  two  feet  long,  padded, 
to  be  bandaged  at  each  end  to  the  legs  to  maintain  their 
separation. 


Fig.  14.    Table  arranged  for  operation  in  lithotomy  position. 


One  large  table  or  bureau  may  be  used  for  instruments, 
dressings,  sponge  basins,  etc.,  but  it  is  better,  if  a  nurse 
or  second  assistant  is  at  hand,  to  place  one  (or  two)  tables 
for  the  instruments  and  sterilized  dressings  on  the  side  at 
which  the  assistant  is  to  stand,  and  another  table  for  sponge 
basins,  towels,  etc.,  on  the  side  of  the  operator.  The  nurse 
detailed  to  the  care  of  the  sponges  is  then  able  to  relieve 
the  operator  in  the  manipulation  of  retractors,  etc.  If  the 
assistant  is  not  fairly  familiar  with  the  technics  of  the  opera- 
tion or  those  of  the  individual  surgeon,  it  may  be  well  to 
place  the  instrument  table  where  the  operator  can  help  him- 
self to  what  he  wants.  For  this  purpose  an  invalid's  feed- 
ing table  projecting  over  the  patient's  body  is  very  con- 
venient for  holding  the  instruments  in  immediate  use.   These 


62  The  Surgical  Assistant. 

tables  should  be  covered  with  sterilized  sheets  or  with  towels 
and,  if  their  tops  are  polished,  with  some  waterproof 
material  also. 

Window-curtains  should  be  drawn  aside  and  pinned  or 
tied  back.  If  it  is  possible  for  curious  neighbors  to  see 
into  the  room  through  the  window  panes,  these  should  be 
soaped.  This  is  accomplished  by  passing  over  them  a  wetted 
cake  of  soap  or  the  palm  of  the  hand  smeared  with  lather. 
The  more  irregularly  the  streaks  of  soap  are  applied  the 
more  the  rays  of  light  will  be  diffracted. 

The  assistant  now  lays  out  in  systematic  order  upon 
a  bookcase,  mantel-shelf  or  table,  the  supplies  that  have  been 
purchased,  the  operating  aprons,  gowns  and  caps,  etc.  Of 
these,  one  or  two  jars  of  gauze  and  the  jar  of  sea-sponges 
are  placed  upon  the  table  for  sterilized  dressings,  or  at  the 
back  of  the  instrument  table. 

The  sterilized  fountain  syringe,  if  one  is  to  be  used,  may 
be  suspended  from  the  chandelier  or,  by  means  of  a  piece 
of  twine  or  bandage,  from  a  picture-molding  or  curtain-pole, 
thus  to  avoid  driving  a  nail  into  the  wall.  The  irrigating 
solution  should  not  be  poured  in  until  just  before  the  opera- 
tion is  begun,  and  it  should  be  prepared  in  a  pitcher — not 
mixed  in  the  bag. 

The  anesthetist's  table  is  now  supplied  with : 

Chloroform  and  ether,  chloroform  and  ether  masks, 
mouth-gag  (appendix,  figure  5),  screw-gag,  tongue-forceps, 
sponge  holder  (e.g.,  a  clamp)  and  sponge,  vaselin  or  albo- 
lene,  a  basin  to  receive  vomitus,  a  few  towels,  a  safety- 
pin  or  bandage  for  fastening  a  towel  about  the  head,  a 
tumbler  of  boiled  water,  a  sterilized  hypodermatic  syringe 
and  needle,  laid  across  the  tumbler  and  filled  with  strychnin 
sulphate,  gr.  1-30  dissolved  in  whiskey. 

If  a  chloroform  dropper  is  not  supplied,  there  should  be 
cut  two  V-shaped  gutters  in  opposite  sides  of  the  cork  of 
the  chloroform  bottle, — one  groove  for  the  entrance  of  air, 
the  other  for  the  egress  of  the  anesthetic  (see  page  94).  A 
mask  for  the  administration  of  chloroform  may  be  im- 
provised by  drawing  a  corner  of  a  towel  through  a  safety- 


Preparation  of  an  Operating  Room. 


63 


pin.  An  ether  mask  may  be  quickly  fashioned  by  folding  a 
newspaper  twice  across  its  width,  and  laying  this  lengthwise 
in  a  towel.  The  edges  of  the  towel  are  turned  in,  and  the 
paper  and  towel  are  then  folded  over  into  a  hollow,  flat- 
tened cylinder  of  appropriate  size.  The  loose  end  is  pinned 
down  and  one  of  the  open  ends  is  also  closed  with  pins. 
Into  the  apex  of  the  cone  thus  formed  is  stuffed  absorbent 
cotton  or  gauze.  The  use  of  a  gas-ether  apparatus  renders 
many  of  these  articles  unnecessary. 


'      '      J 


Fig.  15.  Arrangement  for  anesthetist,  a,  chloroform  mask  ;  b,  ether 
mask  ;  c,  screw-gag ;  d,  mouth-gag ;  e,  sponge  on  holder  ;  /;  towels ;  ^,  pus 
basin;  k,  tumbler  of  sterile  water  and  hypodermatic  syringe  (loaded); 
?',  chloroform  bottle  ;  /,  ether  can  ;  A,  vaselin  or  albolene. 


The  basins  and  dishes  should  now  be  distributed.  On 
the  wash-sink  are  placed  two  hand  basins.  In  one  is  poured 
alcohol,  50  to  95  per  cent.  The  other  is  to  be  filled  with  sub- 
limate solution,  I- 1000,  and  in  it  are  placed  a  hand-brush 
and  an  orange  stick.  In  the  sink,  which  should  be  scrubbed 
and  scalded  out,  are  placed  another  hand-brush  and  nail 
cleaner.  The  pot,  tube,  or  bottle  of  soap  is  placed  alongside ; 
as  are  also  basins  containing  a  saturated  solution  of  perman- 
ganate of  potash  and  an  8  to  10  per  cent,  solution  of  oxalic 
acid,  respectively,  and  the  box  of  chlorid  of  lime  and  the 
crystals  of  sodium  carbonate — if  either  of  these  methods 
of  disinfection  is  to  be  used.    On  each  side  of  the  operating 


64 


The  Surgical  Assistant. 


table  is  placed  another  hand  basin,  and  in  it  is  to  be  made 
a  sublimate  solution,  1-2000.  On  the  nurse's  table  are 
placed,  if  needed,  two  basins  for  rinsing  sea-sponges,  to  be 
filled  with  boiled  water  or  sublimate  solution,  1-2000.  Upon 
the  instrument  table  are  placed  one  or  two  shallow  dishes, 
to  contain  alcohol  for  ligatures  and  sutures;  one  deep  dish 
to  contain  sublimate  solution,  1-500,  for  immersing  ligature 
bottles  or  tubes,  a  sponge,  and  a  piece  of  gutta-percha  (which 
latter  should  previously  be  washed  in  cold  soapsuds  and 
rinsed  in  alcohol) ;  one  dish  to  contain  sterile  water  or  weak 
carbolic  acid  solution  for  cleansing  instruments;  the  speci- 
men dish ;  a  tumbler  or  butter-dish  to  contain  a  little  pure 
carbolic  acid,  if  needed  for  cauterizing  an  appendix-stump ; 
and  trays  to  be  filled  with  sterile  water  or  carbolic  acid  solu- 
tion, I  per  cent.,  if  the  surgeon  prefers  them  to  spreading  the 
instruments  out  upon  sterile  towels.    Lastly,  a  shallow  dish 


Fig.  16.  Arrangement,  in  order,  of  accessories  on  mantel-shelf  or  other 
piece  of  furniture,  a,  razor  ;  d,  basin  with  brush  and  water  for  scrubbing 
patient ;  c,  soap  ;  d,  two  dry  towels;  e,  alcohol  bottle  ;  /,  absorbent  cotton  ;  g; 
bandages  ;  //,  adhesive  plaster  ;  2,  safety-pins ;  7,  binder ;  ^,  ^,  /&,  bottles  of 
bichlorid  tablets,  carbolic  acid,  etc. 

is  filled  with  hot  water  for  cleansing  the  field  of  operation. 
Upon  the  edge  of  the  dish  is  placed  some  green  soap,  and 
in  the  water  are  laid  a  hand-brush  or  a  mop  of  absorbent 
cotton,  and  a  shaving  brush.  This  dish  is  placed  with  the 
unsterilized  supplies  and  alongside  of  it  are  arranged  a  razor, 
two  dry  towels  and  the  unused  alcohol — as  shown  in  dia- 
gram 16.  Here,  too,  may  be  placed  a  wide-mouthed 
specimen  bottle,  or  jar,  containing  2  per  cent,  formaldehyd 
solution. 
The  packages  of  towels,  now  thoroughly  sterilized,  are 


Preparation  of  an  Operating  Room.  65 

lifted  from  the  boiler  and  placed  upon  a  clean  dish  or  in 
weak  sublimate  solution  to  cool.  The  boiler  is  lifted  from 
the  range  and  placed  in  a  corner  of  the  room,  where  it  can 
be  drawn  upon  to  make  and  replenish  the  solutions.  The 
pitcher,  lifted  out  and  placed  upon  a  sterilized  towel,  is  used 
to  dip  out  the  hot  water.  The  demijohn  of  distilled 
water*  is  placed  nearby.  Its  cork  is  replaced  by  a  plug  of 
absorbent  cotton,  after  wiping  the  neck  and  mouth  of  the 
demijohn  with  a  sponge  moistened  in  some  antiseptic  solu- 
tion. In  filling  the  basins  it  is  to  be  remembered  that  neither 
unenamelled  metal  dishes  nor  water  containing  washing  soda 
should  be  used  in  making  sublimate  solutions. 

The  instruments  should  now  be  "  boiled "  in  water  to 
which  has  been  added  a  handful  of  washing  soda.  A  fish- 
boiler  makes  an  excellent  sterilizer.  While  this  is  on  the 
fire  the  assistant  should  uncover  the  gauze  and  sponge  jars, 
and  place  the  ligature  tubes  and  the  strip  of  rubber  tissue 
in  the  basin  of  strong  sublimate  solution.  Then  he  puts 
on  his  apron,  cap,  and  mouth-cover,  thoroughly  sterilizes 
his  hands  and  forearms,  and  dons  his  sterile  gown. 

The  instruments  are  lifted  out  of  the  sterilizer  and  freed 
of  soda  by  dumping  them  in  the  instrument  trays  or  by 
pouring  boiled  water  over  them.  If  no  instrument  trays  are 
used — and  when  the  hands  have  been  in  oxalic  acid  the  in- 
struments will  be  found  very  slippery  unless  used  dry — ster- 
ilized towels  are  lifted  out  of  the  package  and  spread  out 
(handling  them  by  their  borders)  for  the  instruments.  Wet 
towels  soak  up  infectious  materials  through  their  meshes, 
so  they  should  be  spread  in  sufficient  thickness. 

The  instruments  are,  now  arranged  neatly  and  systemati- 
cally according  to  the  order  in  which  they  will  be  needed. 
With  a  pair  of  forceps,  sponges  are  lifted  from  their  jar. 
One  is  dropped  into  the  dish  of  sublimate  solution,  1-500; 
another  into  the  instrument-cleaning  dish,  and  several  into 

*  Even  if  this  water,  commercially  prepared,  is  not  absolutely 
sterile  it  certainly  is  sufficiently  so  for  the  preparation  of  antiseptic 
solutions,  and  its  employment  saves  much  time  in  preparing  cold 
sterile  water— time  that  in  urgent  cases  cannot  be  spared. 


66 


The  Surgical  Assistant. 


the  first  sponge  basin.  Gauze  sponges  previously  prepared, 
or  cut  now  from  the  steriHzed  gauze,  are  laid  upon  a  sterile 
towel  on  the  nurse's  table  together  with  sponge  handles. 
The  latter  should  never  be  allowed  to  remain  in  the  sponge 
basin  if  it  contains  subHmate  solution,  nor  to  touch  the  rim 
of  the  basin  unless  the  latter  has  been  boiled  or  is  covered 
with  a  sterilized  towel  or  sirip  of  gauze.     Packings,  pads. 


Fig.  17.  Instrument  table,  a,  sterilized  towels  ;  b,b,  gauze  jars;  c,  sterile 
adhesive  strips  ;  </,  sterile  absorbent  cotton  ;  e,  dish  of  alcohol  for  prepared 
sutures  and  ligatures  ;  f,  dish  of  sublimate  solution,  one-fifth  per  cent.,  for 
ligatures  in  bottles  and  gutta-percha  ;  ^,  basin  with  sponge  for  cleansing  in- 
struments ;  h,  packings ;  t,  sterilized  safety-pins  ;  j\  needles  ;  k,  aspirating 
syringe  ;  /,  the  other  instruments  arranged  in  the  order  in  which  they  will  be 
needed  ;  tn,  pads  ;  n,  drainage  tubes. 


and  drainage  strips  of  appropriate  size  and  number  are  cut 
and  laid  out  on  the  instrument  table.  Some  or  all  of  the  liga- 
ture- and  suture-tubes  are  emptied  into  the  shallow  dish  of 
alcohol.  A  supply  of  ligature  strands  is  cut  and  arranged 
in  the  dish  in  little  rolls.  Two  each  of  all  the  kinds  of 
sutures  that  will  be  needed  are  threaded  and  placed  neatly  in 
the  same  dish. 

With  this  arrangement  of  the  instrument  table,  to  be  dis- 
cussed again  in  detail,  the  assistant  has  completed  his  prepa- 
rations. 


Preparation  of  an  Operating  Room. 


67 


Proceeding  with  dispatch  and  with  such  a  system  as  is 
here  outHned,  and  directing  systematically  those  who  may 
be  at  hand  to  help  him,  an  assistant  can  in  one  or  two  hours 


Fig.  18.  Arrangement  of  table  for  second  assistant  (nurse's  table),  a,  a, 
first  and  second  sponge  basins;  b,  sponges  in  sponge  holders;  c,  sterilized 
towels;  d,  sterilized  gauze,  sponges  and  pads. 


transform  the  parlor  of  a  mansion  or  the  kitchen  of  a  tene- 
ment into  an  operating  room  equipped  and  ready  for  major 
aseptic  surgery. 


CHAPTER  V. 

PREPARATIONS  FOR  AN  OPERATION. 

THE   PATIENT. 

The  preparation  of  a  patient's  digestive  tract  and  the  pre- 
Hminary  preparation  of  the  field  of  operation  concern  the 
surgeon  rather  than  the  assistant,  in  private  practice  at  least, 
and  these  details,  important  though  they  are,  cannot  logi- 
cally be  discussed  here  (see  appendix  I).  Of  those  prepara- 
tions immediately  preceding  an  operation,  however,  a  few 
words  should  be  said. 

Carrying  a  patient  from  bed  to  table  requires  considerable 
knack.  Unless  the  individual  is  quite  heavy  he  may  often 
be  more  conveniently  carried  by  one  man  than  by  two  or 
more. 

Figure  19  illustrates  how  this  is  accomplished.  The 
patient's  body  is  rolled  upon  the  assistant's  forearms 
(held  in  the  manner  shown),  and  against  his  chest  which, 
thrown  somewhat  backwards,  supports  the  weight  without, 
as  a  rule,  any  great  strain.  If  the  patient  is  narcotized  the 
head  should  be  held  low.  The  arms  must  not  be  allowed 
to  hang  down  even  for  the  short  space  of  time  elapsing 
before  the  table  is  reached. 

Figure  20  illustrates  the  conveyance  of  a  person  by  two 
men.  Obviously  the  assistants  should  arrange  themselves, 
in  lifting  the  body,  with  reference  to  the  side  of  the  table 
or,  after  the  operation,  the  side  of  the  bed,  to  which  the 
patient  is  to  be  restored. 

It  is  well  to  place  the  patient  at  once  in  the  position  upon 
the  table  which  he  is  to  occupy,  for  shifting  afterwards  is 
awkward.  The  arms  should  be  so  disposed  that  they  are 
not  subjected  to  any  pressure  or  stretching  (see  page  86). 

68 


Preparation  of  a  Patient  for  Operation.         69 

If  the  operation  is  one  that  requires  a  preliminary  lavage  of 
the  stomach  that  has  not  already  been  performed,  the  assist- 
ant should  next  give  his  attention  to  this  (page  200). 

It  will  save  much  trouble  and  discomfort  if,  before  the 
field  of  operation  is  disinfected,  the  patient's  clothing  is  rolled 
up  far  enough  to  prevent  soiling  and  wetting.  Thus,  the 
night  shirt  and  undershirt  should  be  drawn  well  up  to  the 
shoulders  posteriorly  if  a  laparotomy  is  to  be  performed. 


Fig.  19.    Lifting  and  carrying  a  patient. 

A  blanket  or  sheet  is  then  spread  over  the  parts  of  the  body 
not  to  be  exposed  for  the  operation,  but  the  movements  of 
the  chest  must  not  be  impeded  by  heavy  covering.  A  rub- 
ber sheet  turned  over  the  edge  of  the  blanket  will  preserve 
it  from  soiling. 

The  field  of  operation  must  then  be  cleansed  over  a  wide 
area.     Even  if  the  parts  are  not  "  hairy  "  they  should  be 


70 


The  Surgical  Assistant. 


shaved.  Cleansing  with  green  soap  and  hot  water  by 
means  of  a  stiff  brush  or  a  soft  cotton  mop,  as  the  operator 
may  prefer,  must  be  thorough  in  either  case  and  per- 
formed with  clean  hands.  Abundant  lather  is  necessary, 
but  not  more  important  than  a  sufficiency  of  water,  which 
it  is  well  to  apply  from  time  to  time  during  the  scrubbing. 
Folds  and  crevices  of  the  skin  and  especially  the  vimbilicus 
(in  abdominal  operations)  must  be  cleansed  deliberately  and 


Fig.  20.    Transportation  of  a  patient. 


thoroughly.  For  operations  upon  the  foot  the  interphalan- 
geal  spaces  should  be  vigorously  rubbed  with  a  strip  of  gauze 
or  the  edge  of  a  towel  dipped  in  soapsuds,  and  the  nails 
should  be  trimmed  and  scrubbed  carefully. 

The  parts  are  then  wiped  with  one  end  of  a  dry  towel, 
and  with  the  other  end  (wrapped  about  the  hand,  barber 
fashion)   alcohol  is  applied  over  the  entire  surface.     This 


Preparation  of  a  Patient  for  Operation.         71 

may  be  followed  by  a  wiping  with  ether.  lodoform-ether 
may  be  poured  into  the  umbilicus  and  other  crevices,  where 
it  forms  a  protecting  film.  The  final  cleansing  of  the  field 
with  ^  per  cent,  sublimate  solution  or  other  antiseptic, 
should  be  left  until  after  the  assistant  has  again  disinfected 
his  own  hands  and  the  sterilized  towels  are  spread.  Disin- 
fection of  the  patient's  skin  by  chlorid  of  lime  and  carbonate 
of  soda  is  as  described  below  for  the  assistant's  hands. 

With  the  exercise  of  a  little  judgment  the  towels  may 
be  disposed  about  the  field  of  operation  economically  and 
yet  in  sufficient  number.  They  should  be  handled  only  by 
their  edges.  One  is  laid  above,  and  another  below  the  field 
and,  without  touching  anything  else  in  the  manipulation. 


Fig.  21.    Arrangement  of  sterilized  towels  for  laparotomy. 

folded  over  the  edge  of  the  blanket  underneath.  It  is  well 
next  to  apply  towels  at  each  side,  then  transversely  laid 
towels  which,  crossing  over  these,  hold  them  from  slip- 
ping off  the  table  (Fig.  21.)  Sterilized  safety-pins  may 
be  used  to  catch  them  more  securely,  if  necessary,  but  it 
must  be  remembered  as  a  matter  of  aseptic  accuracy,  that 


72  The  Surgical  Assistant. 

the  points  of  these  pins  as  they  emerge  from  the  under  sur- 
faces of  the  deepest  towels  are  no  longer  sterile,  and  they 
should  not  be  touched  when  the  pin  is  closed.  Enough 
towels  should  be  spread  (transversely)  to  cover  most  of 
the  body  and  the  table,  leaving  exposed  for  the  operation 
a  much  smaller  field  than  has  been  disinfected.  Two  layers 
of  towels  should  be  used  in  the  immediate  neighborhood 
of  this  field,  and  during  the  operation  wet  and  bloody  ones 
should  be  replaced  or  covered.  A  sterilized  sheet,  with  an 
opening  through  which  to  operate,  may  be  spread  over  the 
body  in  place  of,  or  in  addition  to,  the  towels. 


THE    ASSISTANT    HIMSELF;    TECHNICS    OF    ASEPSIS. 

In  the  familiarity  wuth  aseptic  detail  on  the  part  of  those 
who  help,  the  surgeon  must  enjoy  absolute  confidence.  An 
assistant  who  needlessly  handles  sponges,  instruments,  or 
dressings  "  because  they  are  sterilized,"  or  puts  one  unnec- 
essary finger  into  the  wound,  or  rests  his  hands  upon  his 
hips,  "  because  his  gown  has  been  disinfected,"  has  not  yet 
learned  that  the  essence  of  asepsis  consists  in  avoiding,  as 
far  as  possible,  contact  with  everything,  sterilised  and  un- 
sterilized.  Nor  will  he  be  thoroughly  versed  in  aseptic  prin- 
ciples until,  to  him,  their  every  application  becomes  instinc- 
tive, their  practise  automatic ! 

Surgeons  are  often  timid  of  allowing  the  family  physician 
to  assist  in  an  operation  solely  because  he  may  lack  a  famili- 
arity with  asepsis,  for  which  a  merely  theoretical  under- 
standing cannot  be  substituted.  To  the  acquirement  of  this 
practical  experience  even  the  occasional  assistant  should  give 
his  most  conscientious  attention. 

Thorough  preliminary  disinfection  is  only  a  part,  but  a 
vital  part,  of  aseptic  technics.  Before  the  "  scrubbing  up  " 
is  begun  the  assistant  should  don  a  rubber  apron  for  the 
protection  of  himself,  and  a  mouth-mask  and  cap  for  the 
protection  of  the  patient.  These  latter  can  be  fashioned  from 
a  piece  of  gauze  stretched  over  the  scalp,  the  ends  being 
crossed  beneath  the  occipital  protuberance,  brought  forward 


Preparation  of  the  Assistant.  73 

and  spread  over  the  nose,  mouth  (and  beard)  and  tied  at 
one  side.  The  shirt-sleeves  should  be  rolled  up  well  above  the 
elbows;  and  the  scrubbing  should  also  be  beyond  this  level. 
It  must  be  deliberate,  vigorous  and  painstaking.  Hot,  run- 
ning water  is  desirable  and  a  rather  stiff  hand-brush,  suita- 
ble.soap,  and  a  nail  cleaner  are  essential.  After  a  brief  scrub- 
bing of  the  nails  these  should  be  trimmed  rather  short  and 
then  receive  a  preliminary  treatment  with  the  orange  stick 


Fig.  22.    The  assistant  "scrubbed  up  "  and  ready  for  the  operation. 

or  other  cleaner — under  their  edges  and  in  the  skin-fold 
about  their  borders.  After  a  second,  more  prolonged,  scrub- 
bing, the  nails  should  have  a  second  cleaning  with  the  stick. 
Then  follows  a  vigorous,  systematic  scrubbing  from  finger- 
lips  to  elbows — first  one  arm  and  then  the  other,  finger  by 
finger,  area  by  area.     Such  a  scrubbing  requires  scarcely 


74  The  Surgical  Assistant. 

less  than  five  minutes  for  each  extremity.  Since  the  mouths 
of  the  sudoriferous  and  sebaceous  glands,  which  are  thrown 
into  activity  by  the  labor  of  an  operation,  contain  many 
micro-organisms,  Maylard  suggests  the  following  rational 
procedure :  "  The  hands  are  submerged  for  from  five  to 
ten  minutes  in  water  as  hot  as  can  be  conveniently  borne. 
The  effect  of  this  is  to  dilate  all  the  capillary  vessels,  as  in- 
dicated by  the  redness  of  the  skin,  and  thus  excite  into  active 
secretion  the  two  sets  of  glands.  The  soddened  surface 
epithelium  together  with  the  secretions  are  finally  removed 
by  first  massaging  the  hands  under  water,  by  making  one 
rub  the  other,  and  then  using  some  ordinary  soap."  * 

After  the  scrubbing,  the  soap  is  washed  from  the  skin 
with  running  water,  and  the  hands  and  forearms  are  bathed 
for  one  minute  in  alcohol,  50  per  cent.f  to  95  per  cent.  Then 
follows  their  scrubbing  for  three  minutes  in  a  solution  of 
bichlorid  of  mercury,  i-iooo  to  1-2000,  carbolic  acid,  1-40, 
or  lysol,  i-ioo.  By  pressing  the  pulps  of  the  finger-ends  for- 
wards against  the  bottom  of  the  basins,  as  advised  by  Weir, 
the  spaces  under  the  edges  of  the  nails  are  opened  to  the 
entrance  of  the  disinfecting  solution.  For  additional  disin- 
fection, desirable  if  the  assistant  has  recently  been  in  contact 
with  pus  or  other  infectious  material,  the  hands,  after  wash- 
ing in  alcohol  and  before  washing  in  sublimate  solution, 
may  be  immersed  in  a  saturated  solution  of  potassium  per- 
manganate. They  are  then  rinsed  in  water  (after  allowing 
the  excess  of  the  solution  on  the  skin  to  drip  back  into  the 
dish),  and  the  brown  stain  is  removed  by  immersion  in  a 
strong  solution  of  oxalic  acid  (8  to  10  per  cent.) 

For  the  bichlorid  of  mercury  method  there  may  be  sub- 
stituted disinfection  by  "  chlorid  of  lime  "  and  carbonate  of 
soda.  After  the  scrubbing  with  soap  and  water  about  a 
tablespoonful  of  the  lime  and  one  or  two  crystals  of  the  soda 
are  mixed  in  the  palms  with  enough  water  to  form  a  paste ; 
and  this  paste  is  rubbed  for  five  minutes  into  the  nails  and  the 
skin  of  the  hands  and  forearms,  which  are  thus  brought  in 

*  Annals  of  Surgery,  Vol.  XXXV.,  No.  i. 

f  The  weaker  solution  is  the  more  penetrating. 


Preparation  of  the  Assistant.  75 

contact  with  the  free  chlorin  gas  hberated  by  the  mixture. 
The  paste  is  then  washed  off  with  sterile  water.  "  The  ob- 
jectionable odor  which  this  leaves  upon  the  hands  for  several 
hours  may  be  removed  by  washing  them  in  water  contain- 
ing about  lo  per  cent,  of  aqua  ammonia,  the  chlorin  uniting 
with  the  ammonia  to  form  ammonium  chlorid."  * 

Other  modifications  of  the  system  of  disinfection  need 
no  description  in  a  work  of  this  character.  All  methods  need 
considerable  time,  and  with  none  may  the  process  be  hur- 
ried. Often  the  surgeon,  who  has  made  his  own  preparations 
while  the  assistant  has  been  cleansing  the  field  of  operation, 
is  impatient  to  begin  before  the  assistant  himself  has  com- 
pleted the  disinfection  of  his  hands.  This  should  not  cause 
him  to  shorten  his  toilet  nor,  indeed,  should  anything  else 
be  allowed  to  hasten  him  unduly — except,  perhaps,  the  con- 
dition of  the  patient. 

While  an  unsterilized  gown  (for  which  in  emergency  a 
clean  sheet,  properly  draped  about  the  body,  may  be  substi- 
tuted) may,  of  course,  be  worn  during  the  disinfecting  proc- 
ess, it  is  not  until  that  process  is  completed  that  a  sterile  gown 
should  be  put  on.  In  donning  it  the  assistant  should  be 
careful  that  neither  his  hands  nor  his  forearms  touch  any 
part  of  the  gown  that  may  have  brushed  against  his  body. 
Nor,  if  it  buttons  in  the  back,  should  he  attempt  to  fasten  the 
gown  himself.  In  any  event  it  is  advised  as  a  matter  of  rou- 
tine that  he  dip  his  hands  and  forearms  once  more  into  the 
sublimate  solution  after  the  gown  is  on.  Sleeves,  separate 
or  attached  to  the  gown,  are  sometimes  worn  to  prevent 
wound  contamination  by  secretions  from  the  forearms. 

The  employment  of  rubber  gloves  is  the  only  method  we 
possess  of  securing  for  the  animate,  the  same  aseptic  condi- 
tion as  for  the  metal  surgical  tools.  They  constitute  the 
next  and  final  item  in  the  assistant's  personal  preparation. 
If  sterile  talcum  powder  is  not  provided  for  drawing  on 
the  gloves  in  the  proper  way  described  below  they  may  be 
slipped  on  under  water,  which  balloons  out  the  fingers,  or  in 

*  Palmer's  "  Surgical  Asepsis,"  1903. 


76  The  Surgical  Assistant. 

a  weak  lysol  solution,  which  is  lubricating.  That  method  is 
not  to  be  recommended,  however,  for  the  imprisoned  water 
macerates,  and  lysol  irritates,  the  skin,  and  fluid  dripping 
out  of  the  glove  at  the  wrist  may  carry  with  it  into  the 
wound  sodden  epithelium.  Application  of  the  gloves  dry 
is  the  ideal  method,  and  the  technic  is  as  follows:  A  salt- 
or  sugar-"  sifter  "  or  perforated  powder  duster,  filled  with 
pulverized  talcum  or  starch,  is  wrapped  in  a  towel,  and  sub- 
mitted to  live  steam  for  twenty  minutes  in  a  sterihzer,  after 
which  time  the  steam  is  turned  oJff  and  the  powder  dried  in 
the  heat  of  the  apparatus.  The  gloves  are  laid  flat  in  a 
towel,  which  is  then  folded  over  them  in  a  maner  to  both 
cover  and  separate  them.  This  package  is  then  enclosed  in 
another  towel  and  also  sterilized  by  steam  for  twenty 
minutes.  It  is  said  that  the  rubber  is  less  apt  to  adhere  or 
tear  if  dried  in  the  air  rather  than  in  the  sterilizer. 

The  above  is  the  only  method  of  rapidly  preparing  dry 
sterile  dusting  powder,  but  the  gloves  may  be  prepared  at 
the  time  of  the  operation  by  "  boiling  "  them.  If  this  is  done 
in  the  instrument  sterilizer  they  should  be  dropped  in  last 
and  care  should  be  taken  that  they  are  not  placed  in  contact 
with  sharp  metal  points.  Two  long  dressing  forceps  are  also 
to  be  sterilized.  With  these  the  gloves  are  to  be  lifted  out 
by  their  fingers  (to  drain  the  water  from  them)  and  laid 
upon  a  double  thickness  of  sterile  towels.  Their  surfaces  are 
patted  dry  with  the  upper  towel,  and  dusted  on  each  side 
with  the  talcum  or  starch  powder.  Then  the  gloves  are  turned 
inside  out.  To  accomplish  this,  each  one  in  turn  is  seized  by 
the  cuflf  with  one  of  the  forceps  while  the  other  forceps  is 
passed  into  the  glove  and  made  to  grasp  and  pull  upon 
the  "  web  "  between  two  of  the  fingers.*  The  body  of  the 
glove  is  thus  reversed,  but  not  the  fingers.  If  now  the  glove 
is  seized  with  both  the  forceps  at  its  cuff  and  rapidly  twirled 
about  its  long  diameter  it  will  by  its  twisting  seal  up  air 
within  it,  and  pressure  upon  it  (exerted  through  the  towel) 
will  cause  the  air  to  open  out  the  "  fingers  "  with  a  "  pop." 
The  now  outer  surface  of  the  glove  is  patted  dry.    All  this 

*  Collins,  New  York  Medical  News,  August  20,  1904. 


Preparation  of  the  Assistant.  77 

is  accomplished  without  touching  to  the  gloves  anything  but 
the  forceps  and  the  towel — both  sterilized  by  heat. 

Disinfected  and  dried  by  either  of  these  methods,  and 
lying  on  a  towel,  the  gloves  are  thus  to  be  drawn  on : — The 
assistant  dusts  the  talcum  powder  upon  his  dry  hands,  then, 
grasping  the  wrist  margin  of  a  glove  in  a  sterile  tozvel  or 
piece  of  gauze,  he  slips  it  over  the  corresponding  hand.  The 
other  hand  is  similarly  clothed,  lifting  up  the  second  glove 
with  a  fresh  piece  of  gauze  to  pull  it  on.  If  the  fingers  need 
adjusting,  this  is  done  after  both  gloves  are  on  or,  at  least, 
with  still  another  piece  of  gauze  over  the  opposite  hand — 
never  with  the  naked  hand.  Seizing  or  adjusting  a  glove 
with  bare  fingers  defeats  the  very  purpose  of  "  the  boiled 
hand " !  This  is  self-evident ;  and  yet  the  very  frequent 
violation  of  the  proper  technic,  even  by  those  who  are  care- 
ful in  other  details,  makes  necessary  the  minute  instructions 
upon  the  application  of  rubber  gloves,  just  given. 

Cotton  gloves,  if  used  at  all,  must  be  changed  as  often 
during  the  operation  as  they  become  wet.  Gloves  of  either 
material  should  be  of  proper  size,  for  if  the  fingers  are  too 
short,  or  especially,  if  they  are  too  long  the  wearer's  manipu- 
lations will  be  much  hampered.  The  Murphy  rubber  dam 
used  on  the  patient's  skin  serves  a  purpose  similar  to  the 
rubber  gloves.  As  a  substitute  INIurphy  has  recently  em- 
ployed a  solution  of  formalin-sterilized  gutta-percha  (4 
to  8  per  cent,  in  benzin  or  acetone)  which  covers  the  hands 
and  the  patient's  skin  with  an  impervious  coating.  It  does 
not  impair  the  sense  of  touch  and  is  easily  removed  with 
benzin.  For  the  patient,  he  recommends  the  acetone 
solution  and  for  the  surgeon  the  benzin.  "  The  method 
of  application  to  the  [dried]  hands  and  forearn>s  is  that  of 
simple  washing  as  with  alcohol,  care  being  taken  to  fill  in 
around  and  beneath  the  nails.  The  hands  must  then  be 
kept  exposed  to  the  air  with  the  fingers  separated  until  thor- 
oughly dry.  They  may  then  be  washed  in  alcohol,  bichlorid, 
or  any  of  the  antiseptic  solutions  without  interfering  with 
the  coating  or  affecting  the  skin.  It  wears  off  on  the  tips 
of  the  fingers  if  the  operations  be  many  or  prolonged,  when 


78  The  Surgical  Assistant. 

another  application  may  be  made  [to  them]  between  oper- 
ations    ...."* 

Were  it  not  for  its  frequent  breach  by  the  untrained  it  would 
be  unnecessary  to  state  so  obvious  and  elementary  a  rule 
as  that,  once  disinfected,  neither  the  forearms  nor  the  hands 
should  be  allowed  to  come  in  contact  with  anything  not 
sterilized ;  and  that,  if  such  an  accident  occur,  immediate 
re-disinfection  should' be  performed.  But  more  than  this, 
it  is  important  not  to  handle  even  the  sterilized  articles  un- 
necessarily. The  gloved  hand  may  become  contaminated 
during  an  operation  by  contact  with  secretions  from  the 
patient's  or  the  operator's  skin,  while  the  naked  hand  is 
always  a  possible  source  of  contamination  by  its  own  secre- 
tions. Hence,  in  the  course  of  an  operation  the  hands  should 
be  frequently  tvashed  in  the  antiseptic  solution  placed  by 
the  table.  Although  it  contains  a  contradiction,  it  is  a  safe 
principle  for  the  assistant  to  follow  to  have  confidence  in 
his  aseptic  methods;  and  yet  to  regard  the  hands,  and  every 
article  that  has  once  been  touched,  as  possible  sources  of 
error.  In  the  constant  application  of  such  a  rule  he  will 
develop  the  best  technics  of  asepsis.  Thus  it  will  at  once 
restrain  him  from  touching  his  instruments  needlessly,  from 
lifting  them  except  by  their  handles.  It  will  remind  him 
that  instruments  that  were  sterile  when  he  handed  them  to 
the  surgeon  may  not  be  so  after  they  have  been  in  t"he 
wound;  and  that  therefore  neither  his  fingers,  nor  forceps 
that  have  been  used  elsewise,  should  be  introduced  into 
the  jars  of  ligatures  and  packings.  He  will  not  allow  instru- 
ments or  sponges  to  pass  through  too  many  hands.  (Indeed 
an  advantage  of  gauze  sponges,  cjuite  as  important  as  their 
adaptability  to  steam  sterilization,  lies  in  the  fact  that 
they  are  used  but  once  and  but  one  hand  is  needed  to  use 
them.)  Similarly,  he  will  hold  packings  taut  above  the 
patient's  skin  while  they  are  being  introduced. 

These  are  but  a  few  of  the  details  of  asepsis,  to  be  ac- 

*  J.  B.  Murphy,  Journal  American  Medical  Association,  March  19, 
1904.    Second  communication,  September  17,  1904. 


Technics  of  Asepsis,  79 

quired  by  training  and  by  the  application  of  sound  principles. 
The  others  are  far  too  numerous  to  mention.  There  may 
be  stated,  however,  for  the  assistant  to  take  to  heart,  a  few 
"  aseptic  dont's:" 

Don't  "  scrub  up  "  hastily — either  the  patient  or  yourself. 

Don't  forget  to  rinse  your  hands  frequently  during  an 
operation. 

Don't  fail  to  re-disinfect  after  contact  with  unsterilized 
articles,  by  immersing  in  an  antiseptic  solution  or  by  scrub- 
bing again,  if  necessary. 

Don't  let  your  arms  touch  your  gown,  even  though  it  be 
sterilized. 

Don't  touch  anything  needlessly. 

Don't  pass  instruments  or  sponges  through  too  many 
hands. 

Don't  put  your  finger  in  the  wound  if  an  instrument  will 
do  as  well. 

Don't  put  either  in  the  wound  without  reason. 

Don't  expose  too  large  a  "  field  of  operation." 

Don't  neglect  to  keep  the  area  about  the  wound  (and  in 
the  wound)  clean  and  dry. 

Don't  sponge  into  the  wound. 

Don't  allow  sutures,  gauze  or  instruments  to  drag  over 
uncovered  skin. 

Don't  rest  your  hands  on  the  patient's  skin. 

Don't  allow  your  head  to  come  close  to  the  wound. 

Don't  allow  your  head  to  rub  against  the  operator's. 

Don't  spread  your  arms  over  the  patient's  body. 


80  The  Surgical  Assistant 

Don't  allow  your  elbows,  or  the  operator's  elbows,  to  touch 
instruments  on  the  patient's  body. 

Don't  fail  to  watch  constantly  for  errors  in  aseptic  tech- 
nic ;  don't  hesitate  to  call  attention  to  them  at  once. 

Don't  talk! 


CHAPTER  VI. 
THE    ANESTHETIST. 

The  assistant  who  administers  the  anesthetic  shares  with 
the  surgeon,  to  a  far  greater  degree  than  does  any  other  of 
those  who  help  at  an  operation,  the  responsibihty  for  the 
welfare  of  the  patient;  he  occupies  towards  the  surgeon  a 
peculiar  relationship — a  relationship  which  in  the  conduct 
of  their  work  should  be  mutually  recognized. 

Only  a  grave  emergency  justifies  the  administration  of  a 
general  narcotic  by  one  who  has  not  had  tuition,  and  at  least 
reasonable  experience.  For  this  reason  and  because  detailed 
instruction  can  be  found  elsewhere,  it  is  intended  here  to 
deal,  for  the  most  part,  with  some  practical  points  not  always 
emphasized  in  text-books. 

The  choice  of  the  anesthetic  is  usually  made  by  the  oper- 
ator. Nevertheless,  since  it  is  of  the  greatest  importance  for 
the  narcotizer  to  appreciate,  so  we  may  logically  review,  the 
effects  upon  the  various  organs  of  ether  and  of  chloroform, 
and  the  chief  indications  and  contra-indications  in  the  use 
of  each.  Chloroform  is  a  cardiac  depressant,  ether  a  cardiac 
stimulant.  Ether  is  therefore,  generally  speaking,  safer  and 
except  for  those  who  are  expert,  it  is  the  anesthetic  of  choice 
when  no  contra-indication  to  its  administration  is  present. 
Although,  in  the  author's  experience,  respiratory  paralysis 
is  far  more  frequent  during  chloroformization  than  is  cardiac 
failure,  still  in  those  cases  that  eventuate  fatally  the  deter- 
mining phenomena  are  usually  cardiac.  However,  while 
chloroform  is  therefore  inadmissible  in  the  presence  of  an 
active  heart  lesion,  nevertheless  an  old  endocarditis,  well 
compensated  and  without  marked  circulatory  disturbances, 
does  not  interfere  with  the  administration  of  that  anesthetic 
when,  for  other  reasons,  ether  is  ineligible.    It  must  be  re- 

81 


82  The  Surgical  Assistant. 

membered  too  that  cardiac  failures  during-  chloroformization, 
being  more  striking  (and  more  tragic),  are  more  often  re- 
ported than  fatahties  from  pneumonia  or  suppression  of 
urine  subsequent  to  ether  narcoses.  Ether  is  a  puhnonary 
irritant  and  congestant;  and  the  weight  of  evidence  seems 
to  be  in  favor  of  its  being  also  a  renal  irritant.  For  opera- 
tions upon  the  lungs  or  kidneys,  or  in  the  presence  of  disease 
of  these  organs,  chloroform,  therefore,  should  ordinarily 
be  selected.  While,  with  skill,  ether  can  be  administered  to 
very  young  subjects  by  the  "  open  "  or  "  drop  "  method 
without  inordinate  irritation  of  their  sensitive  air-passages, 
chloroform  is  generally  preferable  for  infants  and  small  chil- 
dren ;  as  it  is  also  for  patients  of  advanced  years,  because  of 
the  greater  danger  of  pneumonia  and,  if  arteriosclerosis  be 
present,  of  cerebral  trouble  from  the  use  of  ether.  If  ad- 
vanced arteriosclerosis  exists,  both  ether  and  chloroform 
are  dangerous  drugs,  and  either  must  be  employed  with 
great  caution.  Ether  causes  cerebral-  congestion  and  is  not 
to  be  preferred  for  intracranial  operations.  For  the  same 
reason,  and  also  because  it  can  be  administered  with  less 
interference  to  the  operator's  manipulations  than  can  ether, 
chloroform  is  to  be  selected  for  operations  upon  the  mouth 
and  throat.  An  important  exception  to  this  rule  exists  in 
anesthetization  for  the  removal  of  adenoid  growths  and  en- 
larged tonsils.  In  these  cases,  ether  is  probably  safer;  but 
accumulating  evidence  indicates  that  in  the  presence  of  the 
status  lyniphaticns,  of  which  adenoid  growths  are  sometimes 
only  an  expression,  ether,  as  well  as  chloroform,  is  distinctly 
dangerous. 

When  it  is  important  to  minimize  the  vomiting  after  opera- 
tion, chloroform  is  ordinarily  to  be  preferred.  As  the 
malaise  after  the  employment  of  ether  is  usually  more  last- 
ing, so  its  initial  effects  (unless  these  be  eliminated  by  em- 
ploying the  gas-ether  sequence)  are  more  disagreeable,  than 
those  of  chloroform,  which  induces  unconsciousness  more 
speedily  as  well  as  more  pleasantly.  This  is  important  in 
selecting  an  anesthetic  for  a  patient  who  is  timid  or  sensitive, 
and  it  is  even  more  important  if  he  be  alcoholic. 


Choice  of  Anesthetic.  83 

Anesthesia  mixtures  (the  A.  C.  E.  and  C.  E.  mixtures*  so 
popular  in  England,  Billroth's  mixture,"}"  the  Schleich  mix- 
tures $  exploited  seven  years  ago,  "Anesthol,"  ft  etc.,)  oc- 
cupy in  a  general  way,  in  regard  to  safety  and  to  effects,  a 
position  between  those  of  chloroform  and  of  ether,  but  they 
may,  of  course,  produce  the  ill-effects  of  either.  Used  by 
some  surgeons  more  or  less  as  a  routine,  these  mixtures  are 
by  others  employed  in  preference  to  chloroform  in  those 
cases  in  which  there  is  an  objection  to  pure  ether,  ^.  g.,  the 
great  age  or  youth  of  the  subject,  the  presence  of  a  bron- 
chial, pulmonary  or  renal  aiTection,  etc.  The  mixtures  are 
sometimes  useful  as  an  introduction  to  chloroform  or  ether 
("  anesthesia  sequence  "),  and  it  cannot  be  denied  that  occa- 
sionally there  is  met  a  subject  who  cannot  be  satisfactorily 
narcotized  by  either  chloroform  or  ether,  but  who  reacts  well 
to  the  skiFful  administration  of  one  of  their  mixtures. 

All  the  foregoing  considerations  impress  the  value  to  the 
anesthetist  of  personally  studying  the  heart  and  the  pulse,  of 
inquiring  into  the  condition  of  the  lungs,  the  kidneys  and, 
in  suspicious  cases,  the  lympathic  system,  of  learning  the 
patient's  temperament  (and  of  removing  false  teeth  or  other 
loose  objects  from  the  mouth),  before  the  narcosis  is  started. 
Nor  should  it  be  begun  until  he  has  provided  himself  with 
one  or  two  towels  and  the  instruments  referred  to  in  a  pre- 
vious chapter — screw-gag  or  hardwood  wedge  for  forcing 

*  A.  C.  E.,  alcohol,  i  part  ;  chloroform,  2  parts  ;  ether,  3  parts. 
C.  E.,  chloroform,  2  parts  ;  ether,  3  parts.  For  a  description  of  the 
uses  of  these  mixtures,  and  as  an  excellent  text-book  upon  the  entire 
subject,  the  reader  is  referred  to  Frederick  Hewitt's  "  Anesthetics 
and  Their  Administration." 

f  Alcohol,  I  part  ;  chloroform,  3  parts  ;  ether,  i  part. 

X  Three  separate  combinations  of  chloroform,  ether,  and  petrolic 
ether  (benzin). 

ff  A  chemical  combination  of  ethyl  chlorid  with  a  "  molecular 
solution  "  of  ether  and  chloroform,  the  liquid  having  a  boiling  point 
closely  approximating  the  temperature  of  the  body;  ethyl  chlorid, 
17^;  chloroform,  36%;  ether,  47^,  by  volume. — Willy  Meyer,  Journal 
American  Medical  Association,  February  28,  1903,  Manufactured 
by  Chas.  Cooper  &  Co.,  New  York. 


84  The  Surgical  Assistant. 

open  the  mouth ;  Denhard  or  other  mouth-gag ;  tongue-for- 
ceps; one  or  more  throat  swabs;  and  a  syringe  loaded  for 
hypodermatic  stimulation — all  of  which  should  be  within 
easy  reach,  but  out  of  the  patient's  sight. 

In  those  cases  in  which  an  emergency  demands  the  admin- 
istration of  a  general  anesthetic  without  previous  prepara- 
tion of  the  patient  a  preliminary  gastric  lavage  may  be  de- 
sirable. 

It  is  conducive  to  cleanliness  to  confine  the  patient's  hair 
in  a  thin  rubber  cap  or  in  a  towel.  One  of  the  long  edges  of 
the  towel  encircles  the  head,  passing  just  below  the  occipital 
protuberance,  just  above  the  ears,  and  across  the  forehead, 
where  the  overlapping  ends  are  caught  with  a  safety  pin. 
The  body  of  the  towel  is  brought  forward  over  the 
scalp,  and  the  two  loose  ends  folded  together  and  secured  at 
the  forehead  with  the  same  pin.  A  few  turns  of  a  bandage 
may  be  used,  instead,  to  hold  the  cap. 

A  preliminary  hypodermatic  injection  of  morphin  (gr. 
1-6 — gr.  1-5  of  the  sulphate)  may  be  made  when  the  opera- 
tion is  apt  to  be  prolonged,  or  when  the  quantity  of  the  nar- 
cotic required  should  for  any  reason  be  minimized.  Chlo- 
retone,  gr.  x-xv,  by  mouth,  has  also  been  recommended.  It 
is  usually  desirable,  and  sometimes  quite  imperative,  to  ad- 
minister morphin  (gr.  1-6 — gr.  1-4)  to  alcoholic  patients. 
It  diminishes  the  intensity  and  duration  of  the  "  excitement " 
they  usually  exhibit,  and  simplifies  a  narcosis  that,  at  best, 
is  apt  to  be  difficult  and  trying.  An  injection  of  atropin 
sulphate,  gr.  i-ioo,  prevents  excessive  mucus  secretion  from 
ether  narcosis.  When  morphin  or  atropin  is  thus  used,  its 
effect  upon  the  pupils  must  be  taken  into  account  in  watch- 
ing the  eye  signs.  Both  pupils  should  be  inspected  before 
the  narcosis  and  during  its  induction,  so  that  the  anesthetist 
may  learn  the  effects  upon  them,  in  the  individual  case,  of 
increasing  and  decreasing  the  doses. 

It  is  important  to  secure  the  confidence  of  the  patient 
from  the  outset,  to  inform  him  of  the  sensations  he  will  ex- 
perience, and  to  instruct  him  to  take  deep  breaths — all  before 
any  narcotic  vapors  are  approached  to  his  face.    The  mask 


The  Stages  of  Narcosis.  85 

should  at  first  be  held  several  inches  away  and  then  brought 
gradually  closer  to  the  nose.  A  brief  cessation  of  respira- 
tion in  the  first  stage,  more  common  during  etherization 
than  in  chloroform  narcosis,  does  not  demand  a  removal  of 
the  mask,  as  it  does  when  occurring  during  profound  anes- 
thesia but,  on  the  contrary,  it  requires  that  the  mask  should 
be  held  in  position  so  that  the  patient  will  receive  with  the 
first  returning  inspiration,  which  is  usually  deep,  a  needed 
dose  of  the  vapor. 

The  stage  of  excitement  is  frequently  absent  (objectively, 
at  least),  often  brief,  and  only  occasionally  troublesome; 
and  slight  restless  movements  should  not  be  restrained.  Al- 
coholics become  pugnacious,  however,  and  large,  plethoric 
individuals  may  be  difficult  to  handle.  To  restrain  the  patient 
then  requires  one  or  more  assistants  to  hold  the  wrists  and 
knees  firmly  against  the  table,  while  the  anesthetist  grips  the 
head  between  his  forearms.  Pressure  upon  the  chest  must 
be  avoided.  An  injection  of  morphin  at  this  stage  is  very 
helpful.  If  ether  is  being  administered  the  mask  should 
be  freely  saturated  and  held  firmly  against  the  face,  all  air 
being  excluded.  Chloroform,  too,  may  be  "  pushed  "  some- 
what but,  unlike  ether,  should  never  be  "  crowded."  Though 
the  patient  be  struggHng  violently  it  is  important  that  some- 
one should  watch  the  pulse,  for  even  in  this  stage  of  incom- 
plete narcosis  dangerous  collapse  may  occur — just  as  occa- 
sionally it  occurs  when  operative  procedures  are  undertaken 
during  insufficient  anesthesia.  After  several  deep  inspira- 
tions the  subsidence  of  the  violent  tremors,  glottic  spasms 
and  cyanosis  marks  the  termination  of  the  stage  of  excite- 
ment ;  but  the  administration  of  the  anesthetic  should  not  be 
remitted  until  the  second  stage*  is  safely  inaugurated.  The 
appearance  of  stertor  (if  it  has  not  already  been  present  in 
these  individuals)  also  marks  the  advent  of  deepening  nar- 
cosis. 

At  this  stage  it  is  important  to  keep  the  air  passages  freely 
open,  for  which  purpose  it  is  well  to  remove  the  pillow  and 
to  extend  the  head — whether  it  be  held  sideways  or  in  the 

*  "  Third  stage  "  of  Snow,  Hewitt,  and  other  authors. 


86  The  Surgical  Assistant. 

median  line.  The  position  of  the  arms  also  must  be  care- 
fully attended  to. 

When  the  site  of  the  operation  does  not  interfere,  it  is  best 
to  place  the  arms  alongside  the  chest,  with  the  forearms 
folded  lightly  across  the  lower  thorax  where  they  may  be 
held  by  rolling  the  bottom  of  the  patient's  shirt  over  them.  A 
paralysis  of  one  of  these  members  after  general  anesthesia 
is  usually  attributable  to  its  having  been  allowed  to  lie  in  a 
vicious  position.  Such  paralysis  is  very  distressing,  for  it  is 
always  of  long  duration  and  is  sometimes  incurable.  For 
its  occurrence  the  anesthetist  must  hold  himself  solely  re- 
sponsible ;  for  its  prevention,  therefore,  he  should  afford  his 
constant  watchfulness. 

Discussing  the  anatomical  factors  in  the  production  of 
narcosis  paralyses,  in  connection  with  the  report  of  a  bilateral 
brachial  palsy  occurring  in  a  patient  upon  whom  the  author 
operated  for  appendicitis,  he  deduced  these  practical  rules :  * 

"  I.  The  care  of  the  arms  is  as  important  a  part  of  the 
anesthetist's  duty  as  is  the  administration  of  the  narcotic. 
They  should  never  be  allowed  to  hang  over  the  edge  of  the 
table.  This  position  threatens  the  musculo-spiral  nerve  by 
pressure,  and  the  entire  plexus  by  stretching. 

"  2.  Rotation  and  superextension  of  the  head  should  be 
exercised  only  while  emergency  requires  it. 

"  3.  Prolonged  pressure  of  any  kind  should  be  avoided,  be 
it  that  of  an  assistant's  hand  or  body,  or  that  of  a  harness. 
When  used,  the  shoulder-strap  of  a  leg-holder  should  pass 
over  the  tip  of  the  shoulder,  or  over  a  large  pad  of  cotton 
wool  on  the  neck ;  or,  best  of  all,  should  be  held  by  an  as- 
sistant (the  anesthetist  can  usually  spare  a  hand  to  pull  the 
strap  up  from  the  bod}-  from  time  to  time).  It  should  be 
remembered  that  this  apparatus  has  occasionally  caused  para- 
lysis in  a  leg,  as  in  one  of  Garrigues'  cases. 

"  4.  The  common  practice  of  drawing  the  arms  alongside 
the  head,  however  much  it  may  contribute  to  the  conveni- 
ence of  the  anesthetist  and  the  comfort  of  the  operator,  is 
a  bad  one  and  should  not  be  tolerated.     Remembering  that  in 

*  New  York  Medical  Journal,  April  27.  1901. 


Signs  to  be  Watched.  87 

some  of  the  cases  reported  the  arms  were  lying  alongside  the 
body  during  the  operation,  the  safest  rule  to  follow  is  to 
avoid  allowing  either  arm  to  remain  more  than  a  fewf 
minutes  in  any  one  position,  hozvever  innocent  that  position 
may  appear  to  he." 

Paralysis  of  a  leg  is  less  apt  to  come  from  the  pressure 
of  a  strap  itself  than  from  the  pressure  of  an  assistant's  body 
upon  the  flexed  extremity.  While  the  anesthetist  is  not  re- 
sponsible for  such  a  fault  he  is  in  a  position  to  call  attention 
to  it.  Nor  should  his  watchfulness  cease  when  the  patient  is 
removed  from  the  operating  table.  He  should  see  that  none 
of  the  extremities  lies  in  a  constrained  position  when  the  pa- 
tient is  returned  to  his  bed.  (That  someone  of  experience 
should  remain  at  the  bedside  until  the  patient  is  "  out  "  of  the 
narcosis  needs  here  no  more  than  the  passing  mention.) 

In  addition  to  the  arms,  the  anesthetist  should  take  con- 
stant note  of  the  patient's  color,  pulse,  respiration,  and  re- 
flexes. 

The  Color  of  the  lips,  of  the  lobes  of  the  ears,  of  the  escap- 
ing blood,  is  an  index  to  the  extent  of  the  oxygenation  in  the 
lungs.  Slight  cyanosis,  especially  during  etherization,  does 
not  call  for  treatment  if  present  from  the  beginning.  Deeper 
cyanosis  is  an  indication  for  freeing  the  air  passages  if  they 
are  obstructed  by  mucus  or  by  the  falling  back  of  the 
tongue,  for  the  allowance  of  more  air,  or  (more  particularly 
in  the  presence  of  other  signs)  for  the  withdrawal  of  the 
anesthetic. 

The  Pulse  should  be  watched  constantly  and  by  the  anes- 
thetist himself.  This  may  be  conveniently  done  at  or  just 
below  the  point  where  the  facial  artery  passes  over  the 
horizontal  ramus  of  the  lower  jaw  (at  the  anterior  border  of 
the  masseter  muscle),  where  the  temporal  artery  crosses  the 
zygoma,  at  some  point  along  the  course  of  the  internal 
carotid,  or  by  holding  the  upper  lip  between  finger  and  thumb 
(superior  coronary  branch  of  the  facial  artery).  Frequent 
reference  to  the  radial  artery  is  helpful,  too,  and,  indeed,  the 
radial  pulse  may  be  watched  throughout — and  without  drag- 
ging the  arm  alongside  the  head  to  accomplish  it. 


88  The  Surgical  Assistant. 

Acceleration  of  the  pulse-rate  is  frequently  to  be  noted 
during  the  first  stage,  but  in  the  second  stage — of  chloroform 
narcosis  more  especially — the  pulse  usually  resumes  about 
its  normal  rate. 

Enfeeblement  of  the  pulse  is  a  matter  of  concern,  but  not 
necessarily  of  alarm.  It  may  have  no  other  significance 
than  an  individual  reaction  to  the  narcotic,  disappearing 
when  the  patient  is  allowed  to  "  come  out " ;  and  a  skilful 
anesthetist  often  carries  a  patient  safely  through  a  pro- 
longed, deep  narcosis,  with  a  pulse  that  is  throughout  of 
poor  quality.  A  pulse  that  is  both  rapid  and  feeble,  how- 
ever, more  especially  if  the  symptom  is  a  progressive  one, 
requires  treatment.  It  must  be  decided  whether  it  is  the  re- 
sult of  shock,  loss  of  blood,  insufficient  aeration  of  the  blood, 
or  the  cumulative  effect  of  the  anesthetic.  Accordingly  it 
will  call  for  haste  in  the  operation,  stimulation,  more  air, 
change  of  anesthetic,  or  withdrawal  of  anesthetic — or  a 
combination  of  these. 

Rapidity  and  enfeeblement  of  the  pulse  often  appearing 
rather  abruptly,  may,  however,  have  a  significance  quite 
diffierent  from  these,  viz.,  that  the  patient  is  "  coining  out," 
or  (and)  that  he  is  about  to  vomit.  Nice  judgment  is  there- 
fore needed  to  determine  which  of  two  opposite  things  is 
required — more  anesthetic  or  less  anesthetic.  If  the  nar- 
cotizer  informs  the  surgeon  that  the  patient's  condition  is 
bad — which  he  should  always  do  when  such  is  the  case,  he 
may  disconcert  the  operator  unnecessarily — which  he  should 
never  do,  and  may  find,  to  his  embarrassment,  that  the 
patient  reacts  vigorously  the  next  moment.  If  he  assumes 
that  the  patient  is  coming  out  and  pushes  the  narcosis,  he 
may  administer  a  lethal  dose  to  an  already  poisoned  heart.  If 
the  condition  of  the  reflexes  does  not  help  him  in  deciding 
which  course  to  pursue,  he  should  withdraw  the  mask  and 
await  further  developments.  At  no  time  should  an  anes- 
thetist administer  a  single  dose  of  the  vapor  without  having 
an  accurate  appreciation  of  hozv  far  the  patient  is  ''under/' 
and  in  what  condition  he  is.  Haphazard  anesthetization  is 
bad  anesthetization ;  and  guesswork  is  never  excusable, 


The  Respiration. 


89 


The  Respiration,  which  may  be  jerky  and  irregular  or 
rapid,  in  the  first  stage,  should  be  regular  and  slow  in  the 
second  stage  of  narcosis,  when  it  is  usually  more  or  less 
stertorous.  Blowing  of  the  cheeks  is  in  most  cases  a  sign 
of  deep  narcosis.  Flapping  of  the  soft  palate  gives  a  stridu- 
lent  or  sonorous  character  to  the  stertor,  which  latter,  being 
due  in  part,  at  least,  to  falling  back  of  the  tongue,  can  usu- 
ally be  overcome  by  lifting  the  jaw  forward.  This  is  accom- 
plished by  pressure  of  the  middle  finger  against  the  angle 
of  the  inferior  maxilla, — the  forefinger  is  thus  left  free  to 
feel  the  facial  pulse,  and  the  thumb  to  test  the  eye  reflexes. 


Fig.  23.  Administration  of  chloroform.  The  jaw  is  being  held  forward  by- 
pressure  of  the  middle  finger  of  one  hand  ;  the  index  finger  is  on  the  facial 
artery  and  the  thumb  is  testing  the  conjunctival  reflex.  Note  also  the  towel 
about  the  head,  which  is  extended  on  a  flat  pillow ;  and  the  unconstrained 
position  of  the  arms  and  hands. 


Supporting  the  jaw  on  one  side  only  will  usually  suffice, 
and  it  is  advisable  to  change  occasionally  from  one  side  to 
the  other  to  obviate  the  soreness  which  otherwise  often 
results  from  continuous  pressure  upon  one  spot.  The  jaw 
may  also  be  held  forward  by  catching  the  lower  incisor  teeth 
in  front  of  the  upper  ones  (if  they  be  large  and  strong),  and 
it  can  be  maintained  in  this  position  by  light  support  with 
one  finger  under  the  chin.    If  extension  of  the  jaw  does  not 


90  The  Surgical  Assistant. 

entirely  overcome  the  stertor,  nothing  further  need  be  done, 
provided  neither  cyanosis  nor  other  sign  indicates  inefficient 
respiration;  and  it  must,  of  course,  be  remembered  that 
during  etherization  engorgement  of,  and  increased  secre- 
tion by,  the  pharynx  are  themselves  causative  of  stertor.  If, 
however,  it  is  evident  that  the  base  of  the  tongue  is  still 
seriously  obstructing  the  air  passage  in  spite  of  the  jaw  ex- 


FlG.  24.    Sponging  mucus  from  the  pharynx.    Mouth-gag  in  position. 

tension,  then  a  screw-  or  wedge-gag  should  be  pried  into 
the  mouth,  between  the  upper  and  lower  molar  teeth,  and 
the  tongue  drawn  forward  by  means  of  forceps.  For  pro- 
longed traction  on  the  organ  this  bruising  instrument  should 
be  replaced  by  a  stout  guy-suture  passed  transversely 
through  the  tongue  near  its  middle. 

The  pharynx  must  be  kept  free  of  mucous  accumulations. 
To  reach  the  cavity  a  metal  mouth-gag  is  introduced  between 
the  jaws,  after  they  are  forced  open  with  the  screw  or  wedge, 
and  the  handles  of  the  instrument  approached.  A  sponge 
firmly  secured  in  a  carrier  is  then  passed  well  down  in  the 
pharynx,  the  walls  of  which  are  cleansed  from  below  up- 
wards by  imparting  a  spiral  movement  to  the  sponge.    This 


Respiratory  Failure.  91 

is  repeated  until  the  throat  is  clear.  Accumulations  in  the 
pharynx  of  mucus,  blood  or  vomitus,  when  the  operation 
is  concluded  and  the  patient  is  reacting,  should  not  be  wiped 
out,  both  because  the  returning  pharyngeal  reflexes  will  in- 
duce their  expulsion  and  becavise  the  irritation  of  the  sponge 
is  apt  to  provoke  vomiting. 

Sudden  stoppage  of  the  respiration,  like  enfeeblement  of 
the  pulse,  is  not  necessarily  ominous  for,  like  the  pulse  sign, 
it  may  merely  presage  reaction.  Often  extension  of  the  jaw, 
strong  pressure  upon  the  thorax  or  slapping  the  chest  with 
a  wet  towel  may  be  all  that  is  necessary  to  restore  respira- 
tion. If  no  other  serious  sign  is  present  the  anesthetist  may 
safely  wait  a  brief  period  for  the  breathing  to  return.  If  it 
does  not,  however,  then  no  further  time  should  be  wasted 
with  tentative  measures,  but  artificial  respiration  (Sylves- 
ter's) should  be  inaugurated  at  once.  It  should  be  vigorous, 
systematic  and  slozv  (synchronous  with  the  manipulator's 
respirations).  The  upward  movement  of  the  arms  should 
be  a  steady  one ;  the  downward  movement  should  be  fol- 
lowed by  strong  pressure  upon  the  sides  of  the  chest.  Atro- 
pin  may  arouse  the  medullary  centre,  and  since  the  heart 
action  will  soon  flag  if  breathing  be  not  restored,  stimulants 
should  not  be  long  withheld.  When  the  heart  begins  to 
fail,  strong  thumb  pressure  or  percussion  over  its  apex  should 
be  practiced,  and  repeated  about  eighty  times  a  minute.  La- 
borde's  tongue  traction  may  be  performed  synchronously 
with  the  artificial  inspiratory  movement.  Dilatation  of  the 
anal  sphincter  is  sometimes  very  useful.  Elevation  of  the 
foot  of  the  table  and  the  application  of  hot  blankets  are  help- 
ful adjuvants.  Finally,  faradaization  of  the  phrenic  nerve 
and  insufflation  of  the  lungs  may  be  tried  if  the  apparatus 
are  at  hand.  None  of  these  methods,  however,  is  as  reli- 
able as  the  artificial  respiration,  which  should  be  persisted 
in  for  hours  if  necessary — until  rhythmic  breathing  is 
restored,  or  until  the  faintest  heart  flutter  has  long  since 
ceased  to  be  heard  and  other  signs  of  death  are  unmis- 
takably present. 

The  Eyes.  Although  the  conjunctival  reflex  is  most  active 


92  The  Surgical  Assistant. 

over  the  cornea  (corneal  reflex),  that  part  of  the  eye  should 
not  be  touched  since  this  risks  the  production  of  an  ulcera- 
tion. The  sclera  may  be  touched  frequently  without  injury 
but  to  elicit  the  conjunctival  reflex  it  usually  suffices  to  lightly 
and  quickly  lift  the  edge  of  the  upper  lid — which  move- 
ment at  the  same  time  exposes  the  pupil  for  inspection.  The 
liveliness  of  the  conjunctival  reflex  is  less  important  than  the 
variations  in  its  activity.  While  generally  a  feeble  contrac- 
tion in  the  orbicularis  when  the  conjunctiva  is  touched,  in- 
dicates a  relatively  deep  narcosis,  and  a  vigorous  contraction 
indicates  a  relatively  light  narcosis,  the  response  is  not  the 
same  in  all  individuals.  Thus  it  is  sometimes  to  be  noted 
that  a  patient  is  quite  relaxed  and  anesthetic  even  though 
the  conjunctival  reflex  is  fairly  active;  and,  per  contra,  an- 
other patient  may  unexpectedly  react  when  this  reflex  is 
absent,  and  ocasionally  when,  also,  the  respiration  is  ster- 
torous, and  the  cheeks  "  blowing."  Changes  in  the  reactibil- 
ity  of  the  lid  are,  however,  very  useful  as  indices  to  fluctua- 
tions in  the  depth  of  the  narcosis. 

The  same  remarks  apply  to  the  size  of  the  pupil.  Although 
it  is  usually  moderately  contracted  during  the  second  stage 
of  the  narcosis  (more  especially  of  chloroform  narcosis),  it 
is  often  dilated  or  of  medium  size.  By  studying  the  pupil 
for  a  few  moments,  however,  the  anesthetist  learns  its  in- 
dividual reactions,  and  by  the  changes  it  undergoes  he  may 
be  able,  unless  much  morphin  has  been  injected,  to  gauge 
very  accurately  the  depth  of  the  narcosis  and  to  conduct  its 
administration  accordingly.  Thus  an  alteration  from  mod- 
erate dilatation  to  contraction  frequently  means  deepening 
of  the  narcosis,  and  vice  versa.  If  extreme  dilatation  of  the 
pupil  occurs  suddenly  during  deep  narcosis,  it  tells  the 
anesthetist  that  he  has  allowed  his  patient  to  approach  too 
near  the  danger  line !  In  light  narcosis  the  pupils  may  dilate 
reflexly  from  operative  manipulation.  Disappearance  of  the 
pupillary  reaction  to  light  indicates  a  dangerously  profound 
narcosis  and  calls  for  withdrawal  of  the  anesthetic  until  the 
reflex  is  re-established. 

By  thus  studying  the  color  of  the  skin,  the  pulse,  the  re- 


Stimulation.  93 

spiration,  and  the  eye  reflexes  the  anesthetist  is  enabled  to 
secure  and  maintain  a  degree  of  narcosis  required  by  special 
cases.  Conditions  present  before  operation,  or  arising  during 
anesthesia,  may  make  it  necessary  to  give  the  patient  but 
little  of  the  narcotic,  viz.,  to  secure  unconsciousness  without 
complete  relaxation,  or  relaxation  without  profound  narcosis. 
During  a  herniotomy  it  may  occasionally  be  helpful  to  allow 
a  patient  to  "come  out "  sufficiently  to  strain  into  view  a  sac 
that  has  slipped  back  into  the  abdominal  cavity.  Operations 
upon  the  anus  require  deep  anesthesia, — stretching  of  the 
sphincter  ani  or  the  cervix  uteri  may  elicit  a  loud  snort  or 
a  vigorous  movement  of  the  legs,  even  when  the  other  re- 
flexes are  abolished. 

Stimulation.  For  bolstering  a  flagging  heart  strychnin 
or  (and)  whiskey  (or  brandy)  may  be  injected  hypoder- 
matically  in  doses,  for  adults,  of  gr.  1-30  and  30  minims, 
respectively,  which  may  be  repeated.  Digitalis  (TTlx  of  the 
tincture)  is  very  serviceable,  as  are  caffein  (e.  g.,  the  sali- 
cylate or  benzoate  of  caffein  and  sodium,  gr.  ii),  adrenalin 
and  nitroglycerin.  Small  doses  of  morphin  (gr.  1-8 — gr. 
1-6)  possess  the  double  advantage  of  stimulating  and  steady- 
ing the  heart  and  of  reducing  the  quantity  of  anesthetic 
necessary  to  maintain  narcosis.  To  combat  shock  occurring 
during  operation  the  assistant  may  order  the  introduction, 
by  means  of  a  piston  syringe,  beyond  the  internal  sphincter 
ani,  of 

Tinct.  digitalis tU  xx 

Whiskey §  i 

Salt 3  ss—  3  i 

Water  (at  1 10°  F  to  120°  F) |  viii— Oi 

In  the  event  of  collapse,  large  doses  of  strychnin  (gr.  1-20 
— gr.  i-io)  and  of  whiskey,  are  indicated.  Ether,  3  ss,  in 
which  may  be  dissolved  a  grain  of  camphor,  may  be  injected 
for  rapid,  though  transitory,  effect.  Finally  intravenous  in- 
fusion may  be  required. 

Vomiting.  Threatened  vomiting  may  usually  be  avoided 
by  "  pushing  "  the  anesthetic.     But  vomiting  that  is  inevitable 


94  The  Surgical  Assistant. 

or  actual  demands  that  the  mask  should  be  removed,  the 
head  turned  strongly  to  one  side  (away  from  the  field  of 
operation,  preferably),  and  the  jaw  pushed  well  forward. 
Steady  pressure  upon  the  left  phrenic  nerve  in  the  space 
between  the  two  heads  of  the  sterno-mastoid  muscle  may 
be  tried  as  a  means  of  controlling  emesis.  Not  until  the 
vomiting  has  ceased  and  the  mouth  and  pharynx  are 
cleansed,  should  the  anesthesia  be  resumed. 

Individual  Methods  of  Administering  the  Various 
Anesthetics. 

Chloroform.  In  emergency  an  ordinary  handkerchief,  or 
the  corner  of  a  towel  passed  through  a  safety  pin  (as  sug- 
gested by  Lister)  may  be  used  as  a  mask,  or  better  than  these, 
as  a  makeshift,  a  piece  of  gauze  stitched  over  a  large  tea- 
strainer.  Ordinarily  there  is  employed  an  inhaler,  such  as 
that  of  Esmarch  or  Laplace,  or  the  very  excellent  one  re- 
cently devised  by  Yankauer*  (appendix,  fig  i.)  Upon  these 
is  stretched  a  piece  of  balbriggan  or  unbleached  muslin,  or  a 
double  thickness  of  surgical  gauze.  Lacking  a  regular  "  drop 
bottle,"  one  may  be  devised  as  described  on  page  62  or,  prob- 
ably better,  "  a  simple  drop  bottle  is  made  by  cutting  two  V's 
in  a  cork  in  opposite  sides.  A  piece  of  absorbent  cotton  long 
enough  to  reach  the  bottom  of  the  bottle  is  placed  in  one  V, 
and  allowed  to  protrude  about  an  inch  ;  the  other  V  serves  for 
an  air  vent.  The  rapidity  of  the  drops  may  be  regulated  by 
inclining  the  bottle,  though  it  should  never  be  tipped  enough 
to  allow  the  anesthetic  to  run  from  the  opening  in  the  cork. 
The  size  of  the  drops  may  be  regulated  by  twisting  the  cotton 
wick  fine  or  coarse.  Another  method  which  works  equally 
well  and  does  not  spoil  the  cork  is  to  place  a  match  in  the 
neck  of  the  bottle  beside  the  cork,  so  that  it  will  not  fit  too 
tight,  and  then  place  in  the  cotton  wick."  f 

*  New  York  Medical  Journal  and  Philadelphia  Medical  Journal, 
June  4,  1904. 
f  B.  F.  Stevens,  American  Medicine,  August  13,  1904. 


Administration  of  Chloroform,  9S 

When  chloroform  is  administered  where  gas  or  a  grate-fire 
is  burning,  it  is  especially  important  that  the  room  be  kept 
ventilated,  for  otherwise  it  becomes  filled  with  phosgen  (car- 
bon oxychlorid),  a  very  irritating  gas  produced  by  the  de- 
composition of  the  chloroform  vapor. 

The  patient's  eyelids,  nose,  cheeks,  lips  and  chin  should  be 
anointed  with  a  thin  layer  of  vaselin  or  albolene  (or  even 
butter)  to  prevent  burning — a  precaution  that  is  unnecessary 
when  the  Yankauer  mask  is  used.  Should  chloroform  drop 
on  the  unprotected  parts  of  the  face,  however,  it  will  do  no 
damage  if  immediately  wiped  off.  If  chloroform  (or  ether) 
fall  into  the  eye,  the  conjunctival  sac  should  be  promptly  ir- 
rigated with  a  little  warm  water.  The  chances  of  such  an 
accident  are  minimized  by  protecting  the  eyes  with  cotton 
pads  or  a  folded  towel. 

Ideal  chloroformization  consists  in  allowing  the  drug  to 
fall,  drop  by  drop,  upon  the  mask,  at  such  regular  intervals 
throughout  as  will  just  maintain,  unfluctuating,  the  desired 
narcosis ;  and  in  ceasing  the  administration  at  such  time  as 
will  allow  reaction  as  soon  as,  but  no  sooner  than,  anesthesia 
is  no  longer  needed.  Practically,  however,  this  method  is 
approached,  but  seldom  actually  carried  out.  Variation  will 
usually  be  found  necessary,  both  in  the  rate  of  administration 
and  in  the  quantity  administered  from  time  to  time ;  and  thus, 
too,  the  drug  will  be  withdrawn  altogether,  now  and  again, 
for  long  or  short  periods,  as  the  profundity  of  the  narcosis 
indicates. 

With  the  exercise  of  skill  and  patience,  children  may  be 
chloroformed  while  sleeping.  When  awake  they  invariably 
cry  when  they  smell  the  vapor;  as  the  crying  subsides  it  is 
wise  to  withdraw  the  mask  for  a  short  time,  for  it  is  just  at 
this  stage  that  children  may  otherwise  inhale  an  overdose. 

For  operations  upon  the  head  or  neck,  the  anesthetist 
should  disinfect  his  hands,  use  a  sterilized  mask,  and  sur- 
round the  chloroform  bottle  with  sterilized  gauze.  He 
should  see  to  it,  here,  that  no  instrument  is  allowed  to  lie  on 
the  exposed  (or  unexposed)  cornea.  For  operations  about 
the  mouth  the  mask  may  be  replaced  by  a  long,  curved,  metal 


96  The  Surgical  Assistant. 

tube,  one  end  of  which  is  introduced  into  the  faucial  opening 
and  the  other  end  connected  by  rubber  tubing  with  the  exit 
pipe  of  an  atomizer.  By  means  of  the  hand  bulb  air  is 
bubbled  through  chloroform  in  the  flask,  and  the  vapor  of  the 
narcotic  is  carried  into  the  patient's  air  passages.  The  same 
device  may  be  used  for  administering  chloroform  through  a 
tracheal  wound  or,  less  elegantly,  a  thin  pad  of  gauze  held  in 
a  sponge  carrier  in  front  of  the  tracheal  opening  may  be  used 
to  carry  the  drug. 

Ether.  There  is  no  need  to  protect  the  face  with  vaselin, 
for  the  skin  does  not  burn  from  contact  with  ether.  Ether 
vapor  is  heavier  than  air  and  highly  inflammable,  for  which 
reasons  no  lamp,  gas  jet  or  fire  should  be  allowed  to  burn  in 
the  room  except  above  the  level  of  the  operating  table 

Open  ("  Drop")  Method.  This  is  conducted  much  as  is 
chloroform  administration,  an  open  inhaler  being  used.  Since 
ether  evaporates  very  rapidly,  however,  several  thicknesses 
of  gauze  should  be  stretched  over  the  mask,  and  it  is  also 
advisable  to  use  an  inhaler  like  that  of  Laplace,  in  which 
much  of  the  gauze  is  covered  with  a  metal  cap,  or  to  stitch 
over  the  gauze  a  piece  of  oiled  silk,  leaving  exposed  a  space 
in  the  center  about  the  size  of  a  silver  dollar.  The  ether  is 
applied  more  freely  than  is  chloroform,  /.  e.,  the  drops  are 
made  to  follow  one  another  more  closely. 

The  open  method  of  etherization  may  be  used  for  adults, 
but  is  especially  applicable  to  children. 

Closed  Method.  The  towel  cone  described  on  page  63 
answers  all  practical  purposes.  Half  an  ounce  of  ether,  more 
or  less,  is  poured  on  the  cotton,  gauze  or  sea-sponge  in  the 
apex,  and  renewed  as  it  evaporates.  The  Allis  inhaler  (ap- 
pendix, fig.  2)  permits  the  introduction  of  the  ether 
from  above  when  the  anesthetist  does  not  wish  to 
lift  the  mask  from  the  face.  Through  the  same 
opening  air  is  drawn  with  each  inspiration,  unless 
the  rubber  sides  are  folded  over  the  top.  The  "  ex- 
citement "  of  the  first  stage  of  ether  narcosis  is  usu- 
ally more  marked  and  more  prolonged  than  in  chloroformiza- 
tion.     Towards  the  end  of  this  stage  a  general  tremor  is  oc- 


Administration  of  Ether.  97 

casionally  noticed.  Occasional!}^,  too,  a  vivid  roseola  makes 
its  appearance  about  the  face,  neck  and  chest.  It  comes  early 
in  the  narcosis,  and  lasts  but  a  few  minutes.  While  in  chloro- 
formization  free  admixture  with  air  is  imperative  at  all 
times,  during  etherization  air  is  usually  needed  (in  relatively 
smaller  amounts)  only  from  time  to  time.  And  so  here,  too, 
remissions  in  the  administration  are  called  for  as  cyanosis, 
stertor,  or  the  profundity  of  the  narcosis  may  indicate.  If 
ether  is  used  during  an  operation  upon  the  head,  its  adminis- 
tration may  be  conducted  under  the  covering  of  a  sterilized 
towel. 

Hewitt  describes  the  use  of  the  Allis  inhaler  and  the  towel 
cone  as  constituting  the  "  Semi-Open  "  Method  of  etheriza- 
tion, and  limits  the  Closed  Method  to  the  employment  of 
Clover's,  Ormsby's,  Bennett's  or  other  apparatus  that  includes 
a  rubber  bag  from  which  the  patient  breathes  his  own  ex- 
halations mixed  with  fresh  ether  vapor.  The  modus  oper- 
andi of  these  excellent  apparatus  is  simple,  and  needs  no 
special  description  here. 

Anesthesia  by  ether  may  be  induced  more  quickly  and 
more  pleasantly  than  by  chloroform,  if  preceded  by  the  ad- 
ministration of  nitrous  oxid  gas.     For  this  purpose  a 

Gas  and  Ether  apparatus,  such  as  Bennett's  (appendix, 
figure  3),  is  desirable.  By  an  arrangement  of  graduated 
stops,  ether  vapor  is  slowly  introduced  into  the  face-piece  as 
the  patient  "  goes  under  "  the  gas,  which  latter  is  gradually 
withdrawn,  the  gas  reservoir  being  replaced  by  an  empty 
rubber  bag  for  collecting  and  returning  the  expired  gases. 
Traps  are  provided  for  the  admission  of  air  in  regulated 
volume. 

Chloroform  and  Ether  mixtures.  These  are  always  to  be 
administered  upon  an  open  mask,  preferably  one  arranged 
as  described  for  the  drop  method  of  etherization.  It  must 
not  be  supposed  that  any  of  these  mixtures  eliminates  en- 
tirely the  dangers  of  either  of  their  chief  components,  and 
"  the  claim  that  the  administration  of  [these]  mixtures  re- 
quires less  care  and  less  watchfulness  than  the  use  of  chloro- 
form or  ether  is,  to  say  the  least,  vicious  in  purpose  and  re- 


98  The  Surgical  AssistANt. 

suit."*  It  was  the  author's  experience  with  the  Schleich 
mixtures  that  the  eye  signs  during  narcosis  are  not  very  re- 
liable guides. 


Fig.  25.  Administration  of  gas  and  ether  by  means  of  a  Bennett  apparatus. 
Head  turned  to  one  side.  Jaw  extended.  Forearms  at  sides  of  chest.  Anes- 
thetist's forefinger  notes  facial  pulse. 

Nitrons  O.vid  narcosis,  as,  indeed,  the  administration  of 
all  general  anesthetics,  should  be  preceded  by  an  examination 
of  the  heart  and  the  mouth.  Unlike  chloroform  or  ether 
it  may  be  "  pushed  "  from  the  start,  the  face-piece  of  the 
apparatus  being  crowded  down  snugly  and  all  air  excluded, 
after  a  preliminary  whiff  or  two  of  mixed  gas  and  air. 
If  the  patient  be  instructed  to  hold  one  arm  up,  the  ar- 
rival of  analgesia,  if  not  of  anesthesia,  will  be  marked 
by  the  falling  of  the  extremity.  Relaxation  is  not  a 
purpose  of  this  narcotic,  and  marked  rigidity  often  ac- 
companies complete  unconsciousness.  The  occurrence 
of  violent  coarse  tremors  or  spasms,  however,  is  an 
indication  for  the  prompt  allowance  of  air.     Cyanosis  is  the 

*  Mt.  Sinai  Hospital  Reports,  Vol.  i,  1898 


Ethyl  Chlorid  Narcosis.  99 

rule,  but  it  should  not  be  allowed  to  pass  beyond  the  point 
of  duskiness,  and  certainly  should  not  be  long  maintained  at 
deep  blueness,  of  the  features.  When  the  narcosis  is  pro- 
longed, or  the  cyanosis  becomes  deep,  the  administration 
should  be  remitted,  and  the  patient  allowed  to  breathe  air  for 
a  brief  period.  That  asphyxia  is  not  essential  to  the  produc- 
tion of  anesthesia  by  laughing  gas  is  shown  by  the  fact  that, 
by  means  of 

Gas  and  Oxygen,  admitted  to  the  face-piece  of  an  appar- 
atus in  regulated  proportions,  from  separate  cylinders,  a 
sufficiently  deep  narcosis  may  be  maintained,  for  an  hour  if 
necessary,  without  the  appearance  of  any  cyanosis. 

Ethyl  Chlorid  general  narcosis  has  such  wide  usefulness  in 
minor  surgery  and,  by  reason  of  the  greater  portability  of  the 
apparatus,  possesses  so  obvious  an  advantage  over  laughing 
gas  that  the  simple  technics  of  its  induction  are  well  worth 
learning.  Like  nitrous  oxid  it  does  not  usually  secure  muscu- 
lar relaxation.  In  spite  of  this  the  writer  has,  without  much 
difficulty,  performed  complete  stretching  of  the  sphincter  ani 
and  clamping  and  cauterization  of  internal  hemorrhoids, 
upon  a  slender  adult  anesthetized  by  ethyl  chlorid.  Various 
masks  have  been  devised  for  its  administration.  That  of 
Breuer  has  an  inspiratory  and  an  expiratory  valve,  the  for- 
mer of  which  opens  from  a  receptacle  for  gauze  or  absorbent 
cotton,  upon  which  the  ethyl  chlorid  is  poured.  A  very 
simple  mask  is  that  of  Ware  (appendix,  figure  4).  It  con- 
sists in  a  short  tube,  about  one  inch  in  diameter,  one  end  of 
which  is  covered  with  two  or  more  layers  of  gauze  and 
thrust  into  the  opening  of  the  simpler,  valveless  form  of  face- 
piece  sold  by  the  S.  S.  White  Dental  Co.  for  nitrous  oxid  ap- 
paratus. This  mask  may  be  improvised  from  a  funnel,  or  a 
cone  of  heavy  cardboard  which,  however,  must  be  fashioned 
to  fit  the  face  closely.  The  ethyl  chlorid  is  sprayed  into  the 
mask  from  a  glass  tube  sold  originally  for  local  anesthesia 
("  kelene  ").  For  economy  and  convenience  of  administra- 
tion there  should  be  selected  only  those  tubes  that  have  auto- 
matic, spring  releases  ;  and  the  patency  of  the  fine  opening  in- 
to the  tube  should  be  tested  when  the  purchase  is  made,    By 


100  The  Surgical  Assistant. 

pressure  on  the  spring  the  ethyl  chlorid  is  sprayed  through 
the  tube  and  on  the  gauze  intermittently,  viz.,  with  each  in- 
spiration. The  expired  air  soon  freezes  upon  the  gauze ;  but 
the  frost  should  not  be  allowed,  by  reason  of  too  rapid  admin- 
istration of  the  drug,  to  close  entirely  the  opening  into  the 
face-piece. 

Flushing  of  the  face,  muscular  spasms  and  a  brief  dila- 
tation of  the  pupils  are  followed,  when  narcosis  appears,  by 
diminution  of  the  contractions  of  the  muscles,  decrease  in  the 
size  of  the  pupil,  and  somewhat  stertorous  breathing.  The 
pulse  rate  is  ccelerated.  The  pupillary  signs  are,  in  general, 
like  those  in  chloroform  narcosis,  but  are  less  constant.  If 
the  anesthesia  is  prolonged  the  administration  of  the  drug 
may  be  remitted  from  time  to  time.  These  remissions  must 
be  for  very  brief  periods  only,  however,  for  the  patient 
"  comes  out  "  as  quickly  as  from  laughing  gas,  and  with  as 
little  after-effect.  (Vomiting  occurs  sometimes;  nausea  is  a 
more  frequent  sequel,  but  usually  does  not  last  long.) 

Ethyl  Broniid.  This  anesthetic  is  less  satisfactory  than 
ethyl  chlorid,  and  probably  less  safe.  It  is  very  important 
with  the  bromid,  and  indeed  with  the  chlorid,  of  ethyl,  to 
secure  a  pure  preparation.  A  towel-cone  or  Ormsby  inhaler 
may  be  used,  about  a  teaspoonful  of  the  drug  being  poured 
on  the  sponge.  The  mask  is  applied  firmly  to  the  face  until  the 
patient  has  inhaled  a  few  times,  after  which  some  air  is  ad- 
mitted. Ethyl  bromid  does  not  seem  suited  for  intermittent 
administration,  nor  for  any  operation  that  is  not  quite  brief, 
e.  g.,  those  that  can  be  accomplished  during,  or  just  after, 
the  administration  of  a  single  "  dose."  It  induces  rapidly  a 
narcosis  that  is  as  quickly  recovered  from.  There  is  usually 
no  struggling.  Respiration  is  free,  sometimes  slightly  snor- 
ing. The  pulse  rate  is  accelerated,  as  a  rule.  The  conjunc- 
tival reflex  may  become  lost  or  may  remain  quite  active";  the 
pupil  usually  dilates.  Unless  the  administration  is  very  brief, 
it  is  followed  by  severe  headache  and  vomiting. 

For  Obstetric  Narcosis  chloroform  is  most  generally 
useful,  although'  ether  is  not  ineligible  for  many  operations. 


Obstetric  Narcosis.  101 

The  manner  of  administration  in  normal  labors  depends 
upon  whether  the  purpose  is  to  alleviate  pain,  to  retard  ex- 
pulsion, or  both. 

In  the  second  stage  of  delivery,  before  the  head  is  at  the 
outlet,  a  "  whiff  "  of  chloroform  may  be  administered  to 
"  take  the  edge  off  ''  a  pain.  For  this  purpose  the  liquid  is 
poured  rather  freely  upon  a  mask  or  handkerchief,  with  the 
advent  of  a  pain,  and  withdrawn  as  the  pain  passes  off. 
When  the  head  is  stretching  the  vulvar  outlet  the  pains  be- 
come more  and  more  frequent  and  severe,  and  so  the  ad- 
ministration of  the  chloroform  is  made  more  continuous  and 
the  patient  is  brought  moderately  "  under."  Thus  the  peri- 
neum is  allowed  to  distend  gradually,  and  the  head  is  de- 
livered by  the  accoucheur,  slowly  and  without  injury  to  the 
maternal  soft  parts.  When  the  head  is  born  the  chloroform 
should  not  be  withdrawn,  for  the  sudden  onrush  of  the 
shoulders  that  would  follow  may  rupture  a  perineum  that 
has  been  carefully  guarded ;  and  even  the  infant  hips  occa- 
sionally do  damage  in  passing.  When  the  child's  body  has 
been  delivered,  however,  the  mask  should  be  removed,  for 
excess  of  chloroform  favors  uterine  inertia  and,  therefore, 
retention  of  the  secundines  and  hemorrhage. 

For  forceps  ddweries  chloroform  should  be  used,  as  a 
rule,  when  the  blades  are  inserted,  and  continued  or  not 
according  as  the  operator  desires  to  deliver  without  or  with 
the  aid  of  maternal  effort. 

For  versions  and  other  intra-nterine  manipulations  moder- 
ate narcosis  should  be  induced.  For  breech  extractions  the 
chloroform  is  needed  when  the  hand  is  introduced  to  seize  a 
foot,  but  unless  the  delivery  is  to  be  hastened,  the  anesthetist 
should  thereafter  remove  the  mask,  and  may  assist  by  exert- 
ing pressure  upon  the  fundus  uteri.  The  narcotic  is  resumed 
if  the  infant's  hands  must  be  brought  down ;  and  the  final 
extraction  is  best  accomplished  under  narcosis  since,  to 
avoid  asphyxia,  the  manipulations  must  be  rapid. 


CHAPTER  VIL 

THE  PREPARATION  AND  PRESERVATION  OF  SURGICAL 
INSTRUMENTS  AND  ACCESSORIES. 

STERILIZATION. 

Most  surgical  instrnmenfs  are  to  be  sterilized  by  "boiling" 
for  ten  minutes  in  water,  to  which  has  been  added  sodium 
carbonate  (washing  soda)  to  prevent  rusting.  A  one  per 
cent,  solution  is  sufficiently  strong  for  the  purpose,  but  it  is 
a  convenient  practice  to  drop  about  a  handful  of  the  salt  into 
the  water.  Delicate  instruments  should  be  laid  on  top  of  the 
others  in  the  sterilizer.  After  boiling,  the  instruments 
should  be  rinsed  free  of  soda  crystals  in  sterile  water  or  in  a 
weak  carbolic  acid  solution.  Excess  of  either  of  these  fluids 
should  be  allowed  to  drain  from  the  instruments,  if  they  are 
to  be  spread  out  on  towels,  although  carbolic  acid  solution  is 
not  apt  to  rust  the  metal  during  the  course  of  an  operation. 

For  hasty  preparation  in  minor  work,  instruments  may  be 
sterilized  by  passing  them  rapidly  through  an  alcohol  or  a 
Bunsen  flame — a  procedure  that  is  not  to  be  recommended 
for  finely  tempered  tools. 

Aluminum  instruments  are  ruined  by  boiling  in  soda  solu- 
tion. They  should  be  sterilized  by  boiling  in  plain  water,  or 
by  passage  through  a  flame. 

Scalpels,  auiputating  knives,  urethral  blades  and  delicate 
scissors  should  not  be  submitted  to  prolonged  boiling.  They 
may  be  sterilized  by  washing  with  soap  and  water,  rinsing  in 
alcohol  and  prolonged  immersion  in  carbolic  acid  solution,  5 
per  cent.,  or  in  pure  lysol.  Boiling  for  half  a  minute  may  be 
substituted  for  the  carbolic  immersion,  without  much  injury 
to  the  cutting  edges. 

Needles  may  be  boiled  with  the  coarse  instruments,  being 

102 


Sterilization  of  Surgical  Instruments.         103 

laid  in  the  sterilizer  in  a  small  dish  or  fastened  on  a  strip  of 
bandage.  Immersion  in  pure  lysol  may  be  substituted  for 
the  boiling.  Needles  are  apt  to  be  ruined  by  sterilization  in 
a  flame,  but  they  may  be  disinfected  hastily  by  dipping  in 
carbolic  acid.  Another  hasty  method,  not  altogether  to  be 
commended,  consists  in  igniting  a  thin  layer  of  alcohol  poured 
over  the  needles  spread  out  in  a  dish. 

Ophthalmic  instruments,  after  boiling  and  rinsing,  should 
be  carefully  dried  with  squares  of  soft,  sterilized  linen. 
Cataract  knives  and  iridectomes  may  be  disinfected  like  scal- 
pels or  by  immersions  in  benzin,  three  per  cent,  formaldhyd 
solution  and  alcohol  successively. 

Male  cystoscopes,  laryngeal  mirrors,  etc.,  cannot  be  sub- 
mitted to  boiling,  at  least  not  in  their  entirety.  The  non- 
metallic  parts  should  be  disinfected  by  thoroughly  cleansing 
in  soap  and  water,  and  bathing  in  5  per  cent,  carbolic  acid 
or  3  per  cent,  formaldehyd  solution ;  or  washed  in  soapsuds, 
dried  and  exposed  to  formalin  vapor,  produced  by  gently 
heating  formalin  powder  or  tablets  in  a  closed  chamber. 

Wooden  handles  split  and  become  swollen  by  repeated 
boiling;  but  since  they  are,  for  the  most  part,  cheaply  re- 
placed, this  is  not  a  serious  matter.  Rawhide  mallets  cannot 
be  boiled  without  serious  injury.  They  are,  therefore, 
undesirable.  If  used  at  all,  they  are  to  be  disinfected  in 
formalin  gas. 

Aspirating  syringes,  entirely  of  metal  or  glass,  or  with 
asbestos  or  rubber  packings,  should  be  boiled.  Those  with 
leather  packings  are  to  be  sterilized  as  follows  :  Draw  up  boil- 
ing soda  solution  into  the  barrel;  dip  the  entire  instrument 
into  the  sterilizer  for  a  few  seconds ;  eject  the  fluid ;  wash  out 
several  times  with  carbolic  acid  solution. 

Injection  Syringes  are  sterilized  in  the  same  manner, 
greater  care  being  necessary,  however,  to  secure  asepsis  of 
the  barrel  and  the  packing.  With  those  that  cannot  be 
boiled,  therefore,  the  washing  out  with  carbolic  acid  should 
be  done  repeatedly  and  followed  by  washing  with  sterile 
water. 

Syringe  needles  are  to  be  boiled  with  the  wires  in  place, 


104  The  Surgical  Assistant, 

and  these  should  not  be  removed  until  the  instrument  is 
needed. 

Rubber  materials.  Instruments  with  well  made  vulcan- 
ized rubber  handles  may  be  boiled  freely,  although  it  occa- 
sionally happens  that  rubber  scalpel  handles  are  warped  and 
decolorized  somewhat  by  the  heat.  Razor  handles  are  quickly 
warped,  if  boiled.  Hard  rubber  pessaries,  tongue  depressors, 
etc.,  also  lose  their  proper  form  in  boiling  water,  and  should, 
therefore,  be  sterilized  in  carbolic  acid  or  other  antiseptic 
solution.  Hard  rubber  hand  syringes  are  to  be  similarly  dis- 
infected, after  cleansing  the  individual  parts  if  necessary. 
''  Fountain  "  and  Davidson  syringes  may  be  boiled,  as  may 
also  tubing,  inhalers,  dam  and  bandages  of  rubber.  It  is  well 
not  to  boil  any  of  these  articles  (unless  they  be  of  red  rubber) 
with  the  metal  instruments,  for  the  latter  are  sometimes  dis- 
colored thereby.  Rubber  gloves  and  finger  cots  of  good 
quality  may  be  boiled  freely.  They  should  be  sterilized 
separately  or  floated  above  the  instruments  in  the  sterilizer, 
to  avoid  tearing  bycontactwith  sharp  metal.  Rubber  cfl^/?^^^r,y 
and  bougies  (appendix,  figures  79-85,  90)  may  be  boiled,  but 
after  being  thus  treated  several  times  they  become  very  soft 
and  must  be  discarded.  Catheters  and  bougies  with  shellac 
surfaces  should  not  be  submitted  to  hot  water,  even  for  a 
moment.  They  may  be  disinfected  by  thorough  cleansing 
in  soap  tincture,  or  antiseptic  soap,  and  immersion  in  car- 
bolic acid  solution.  After  this  they  may  be  dropped  into  a 
tube  of  formaldehyd-glycerin  (three  per  cent.)  in  which, 
indeed,  they  may  be  kept  between  operations.  Exposure  of 
catheters,  dry,  in  a  cabinet,  to  formalin  vaporized  in  a  gen- 
erator can  be  relied  upon  as  an  efficient  means  of  disinfec- 
tion. 

Krotoszyner  and  \Mllard*  recommend  the  following 
methods  of  sterilization  as  proven  by  them  to  be  safe  as  well 
.  a  simple : 

'*  Soft-rubber  catheters  are  rendered  sterile  by  being 
boiled  five  minutes,  preferably  in  sodium  chlorid  solution, 
care  being  taken  that  the  solution  fills  the  lumen  of  the 

*  New  York  Medical  News,  August  27,  1904. 


Sterilization  of  Surgical  Accessories.  105 

catheter.  As  a  matter  of  precaution  the  catheter  should  be 
washed  with  soap-spirits  and  running  water  after  use. 

"  Hard-rubber  and  silk-  and  cotton-woven  catheters  should 
be  boiled  five  minutes  in  a  saturated  solution  of  sulphate  of 
ammonia.  Each  instrument  should  be  wrapped  separately 
in  gauze  or  a  towel,  or  if  several  catheters  are  to  be  sterilized, 
in  such  a  manner  that  their  surface  shall  not  come  in  contact 
with  the  sides  of  the  vessel  or  other  catheters. 

"  Urether-catheters  can  be  folded  and  wrapped  in  a  towel 
so  that  their  surfaces  are  kept  apart,  and  boiled  for  five 
minutes  in  a  saturated  solution  of  ammonium  sulphate." 

"  Instruments  can  be  kept  aseptic  if  they  are  snugly 
wrapped  in  a  piece  of  gauze  or  towel  wet  with  soap-spirits." 
They  "  lay  stress  on  the  fact  that  soap-spirits,  after  the  for- 
mula of  the  German  pharmacopoeia,  is  to  be  used  for  soaking 
the  gauze  or  towel,  as  soap-spirits  prepared  in  other  ways  do 
not  form  the  essential  impermeable  covering." 

Esophageal  probangs  should  be  cleaned  with  soap  and 
water.  The  sterilization  of  gutta-percha  tissue  has  been  de- 
scribed before, — wash  in  cold  soapsuds ;  rinse  in  alcohol ;  im- 
merse in  cold  sublimate  solution  until  needed. 

Suture  Materials.  Catgut  and  kangaroo  tendon  must  of 
necessity  be  brought  to  the  operation  ready  for  use  (see  ap- 
pendix i).  Silk,  silkworm-gut,  horsehair  and  silver  wire 
may  be  sterilized,  if  necessary,  at  the  time  of  the  operation. 
Silk  and  silver  wire  may  be  boiled  with  the  instruments. 
Horsehair,  silk  and  silkworm-gut  are  to  be  boiled  for  thirty 
minutes  in  plain  water,  or  in  5  per  cent,  carbolic  acid  solu- 
tion. Boiling  in  soda  solution  renders  silkworm-gut  soft  and 
friable.  In  emergency,  household  spool  linen  thread,  cotton 
and  silk  may  be  boiled  for  surgical  use ;  they  make  accept- 
able sutures. 

Dressing  gause  and  absorbent  cotton  are  likewise  usually 
employed  commercially  prepared,  or  sterilized  in  the  sur- 
geon's laboratory.  However,  they  may  be  sterilized  in  the 
patient's  home  by  boiling  or  by  steaming  in  a  large  kettle,  and 
drying  in  an  oven.  If  surgical  gauze  is  not  accessible,  dress- 
ing materials  may  be  secured  in  an  emergency,  by  boihn^ 


106  The  Surgical  Assistant. 

strips  of  muslin  or  linen,  which  can  be  quickly  dried  by  press- 
ing with  a  hot  clean  laundry  iron. 

Gaiice  sponges  are  also  sterilized  in  live  steam.  Sea- 
sponges  are  prepared  for  surgical  use  by  a  lengthy  process, 
described  in  appendix  i. 

Wax,  for  plugging  bleeding  bone  surfaces,  should  be 
boiled  and  then  poured  into  a  sterile,  shallow  dish  in  which  it 
is  to  be  kept  (covered)  until  needed  (see  appendix  i). 

Splints.  As  a  refinement  of  asepsis,  splints,  to  be  incor- 
porated in  a  sterile  dressing  may  be  boiled,  if  of  metal,  or 
soaked  in  sublimate  solution,  if  of  wood. 

Hypodermatic  injection  solutions  should  be  sterilized  by 
boiling  if  they  undergo  no  chemical  deterioration  in  the 
process.  Nirvanin  and  beta-eucain  may  be  thus  boiled,  but 
cocain  solutions  should  not  be.  (These  should  be  made  with 
sterile  water,  and  kept  in  well  stoppered  bottles  that  have 
also  been  sterilized.  A  few  crystals  of  boracic,  or  salicylic 
acid,  added  to  cocain  solutions  preserve  them  for  a  consider- 
able time.)  Before  filling  a  syringe  with  a  solution  for 
"hypodermatic  use,  it  is  well  to  rinse  it  out  with  a  little 
sterile  water  or  with  some  of  the  solution  itself.  Cocain 
solutions,  notably,  become  turbid  in  a  syringe  that  contains 
even  a  small  quantity  of  soda  solution ;  the  syringe  needle 
itself  should  be  washed  free  of  this  fluid  before  the  injec- 
tion is  made. 

The  following  procedure  insures  against  "  hypo  "  infec- 
tions, if  the  skin  is  clean:  The  needle  (with  the  wire  in 
situ)  is  boiled  in  water  in  a  tablespoon  and  then  thrown  out 
on  a  clean  towel.  The  spoon  is  again  half  filled  with  water, 
which  is  boiled  and  sucked  up  into  the  syringe  three  or  four 
times  to  disinfect  the  barrel.  A  few  minims  more  of  water 
than  it  is  intended  to  inject  are  then  returned  from  the 
syringe  to  the  spoon  (the  rest  of  the  water  being  thrown 
away)  and  again  brought  to  a  boil.  Then  the  hypodermatic 
tablet  is  dropped  into  the  spoon  and  allowed  to  dissolve  with- 
out further  boiling.  The  solution  is  drawn  into  the  syringe ; 
the  needle,  handled  only  by  its  butt,  is  freed  from  the  wire 
and  screwed  on ;   and  all  air  is  then  expelled  from  the  syringe, 


Cleansing  of  Instruments. 


107 


held  point  upwards,  by  gentle  pressure  on  the  piston.  A 
solid  metal  piston,  unless  it  fits  the  syringe  very  exactly,  has 
a  tendency  to  slide  by  its  own  weight.  An  instrument  with 
such  a  piston  must  therefore  be  held  horizontally  until  the  in' 
jection  is  introduced. 

CLEANSING    AND    PRESERVATION. 

Promptly  at  the  conclusion  of  an  operation,  jars  containing 
sterile  materials  should  be  re-covered,  and  as  soon  thereafter 
as  is  expedient,  the  instruments  should  be  cleaned  and  dried. 
If  they  have  been  in  contact  with  infected  tissues  it  is  desir- 
able to  re-sterilize  them  also. 

The  scalpels  should  receive  attention  first.  They  are  to  be 
washed  off  in  cold  or  tepid  water  (hot  water  would  coagulate 
any  blood  or  other  secretion  that  may  be  upon  them), 
and  carefully  dried.  The  blades  should  then  be  wrapped  in 
absorbent  cotton.  A  hand-brush  should  not  be  used  on  knife- 
blades.     Scalpels  may  be  honed  and  stropped  in  the  same 


Fig.  26.    Testing  iridectome  on  "drum.' 


manner  as  razors  and,  as  with  the  latter,  the  evenness  and 
the  sharpness  of  the  edge  can  be  tested  by  gently  drawing  it 
across  the  end  of  the  thumb-nail  and  of  the  thumb,  respec- 
tively. Cataract  and  Von  Graefe  knives  may  be  tested  on  a 
piece  of  thin,  soft  kid  (from  a  lady's  glove)  or  of  goldbeater's 
skin,  stretched  over  a  napkin  ring.  If  the  point  does  not 
enter  smoothly  but,  instead,  makes  a  crackling  sound  as  it 
pierces  the  membrane,  it  is  not  perfect. 


lOS  The  Surgical  AssistANt. 

The  edges  of  the  blades  of  scissors,  if  "  catchy,"  may  be 
smoothed  to  a  surprising  extent  by  pressure  between  the 
thumb  and  forefinger,  carried  several  times  from  lock  to  tip. 
Scissors  employed  in  the  operation  itself  should  not  ordi- 
narily be  used  also  for  cutting  gauze.  Each  variety  and  size 
of  scissors  has  its  own  capacity,  and  an  attempt  to  use  it  for 
substances  or  thicknesses  beyond  that  capacity  is  apt  to  result 
in  "  springing  "  the  instrument.  Thus,  ophthalmic  scissors 
must  not  be  used  in  ordinary  dissections,  tissue  scissors  are 
not  intended  to  cut  bandages,  nor  bandage  shears  to  cut 
plaster  of  Paris. 

Needles  should  be  dipped  in  alcohol  and  thoroughly  dried. 
The  drying  process  may  be  completed  by  shaking  the  needles 
about  in  lycopodium,  in  a  box  of  which  they  may  be  left  until 
needed  again.  Otherwise,  they  may  be  kept  in  a  strip  of 
gauze,  through  which  their  bodies  are  thrust,  or  laid  away  in 
a  needle-box  or  in  carbonate  of  soda  solution. 

The  coarser  instruments  are  placed  gently  in  a  basin  of 
water.  From  this  they  are  lifted,  one  by  one,  taken  apart, 
scrubbed  with  a  hand-brush,  rinsed,  dried  and  re-assembled. 
It  is  recommended  that  the  assistant  familiarize  himself  with 
the  names  and  mechanisms  of  the  various  surgical  tools. 
Although  many  manufacturers  stamp  the  corresponding- 
blades  of  clamps  and  artery  forceps  with  a  certain  number,  it 
is  best  to  clean  these  instruments  one  by  one,  to  facilitate 
their  proper  re-adjustment.  Locks  and  screws  should  be 
cleaned  and  dried  with  especial  care.  Holes  and  depressions 
are  dried  out  with  wisps  of  absorbent  cotton.  The  drying  of 
instruments  that  have  inseparable  joints  may  be  made  more 
thorough  by  dipping  them  in  alcohol  or,  better,  by  warming 
them  in  an  oven  or  over  a  flame.  The  lumina  of  cystoscopes 
and  other  hollow  instruments  are  washed  out  with  soapsuds, 
then  with  plain  water,  and  dried  by  means  of  absorbent 
cotton  wound  on  a  probe  or  an  applicator.  Ether  may  be 
used,  if  necessary,  to  remove  dried  blood.  A  brush  such  as 
is  used  for  tobacco  pipes  is  useful  for  cleaning  the  channel 
for  ureter  catheters.  The  lumina  of  infusion  canulje,  es- 
pecially,  must  be   made  absolutely  clean  and   dry.     Steel 


Care  of  Instruments.  109 

sounds  must  be  scrupulously  dried  and  polished.  They  are 
to  be  handled  with  some  care  to  prevent  denting  or  roughen- 
ing by  striking  other  instruments  or  by  falling  upon  a  hard 
surface.  Probes  are  easily  straightened  by  rolling  them  un- 
der the  foot.  Wire  and  chain  saws,  and  the  teeth  of  flat 
saws,  are  washed  in  soapsuds,  patted  dry,  wet  in  alcohol  and 
again  dried.  Moisture  still  adhering  in  the  chain  links 
or  between  the  teeth  may  be  driven  ofiE  by  passing  the  saw 
over  an  alcohol  flame.  Rouge  or  crocus  powder  used  oc- 
casionally on  instruments  as  a  polish  helps  to  remove  and  to 
prevent  rust  accumulations.  Oxidation  of  the  surface  of 
silver  instruments  is  easily  treated  by  an  application  of  putz- 
pomade,  which  is  also  useful  for  rust  and  similar  stains. 
Fine  emery  is  often  needed  for  old  rust  spots,  but  it  must  be 
used  very  cautiously  on  nickel-plated  instruments,  as,  in- 
deed, must  all  the  coarse  household  polishing  powders.  Fin- 
ger marks  and  grease  are  removed  by  polishing  or  by  the 
application  of  benzin  or  ether.  lodin,  nitrate  of  silver,  or 
mercurial  solutions  dropping  on  an  instrument  should  be 
wiped  away  at  once.*  Instruments  should  not  be  laid  away 
in  contact  with  soft  rubber,  or  with  bottles  containing  any 
corroding  substance.  Saws,  especially  wire-  and  chain-saws, 
should  be  anointed  with  vaselin  or  "  anti-rust "  before  they 
are  returned  to  the  instrument  cabinet,  which  latter  should 
be  dry  and  reasonably  dust-proof. 

The  efficiency  of  a  hand  syringe  ought  to  be  tested  after,  as 
well  as  before,  an  operation:  The  finger  is  pressed  firmly 
against  the  point  of  the  syringe,  and  the  piston  rod  is  drawn 
out  and  held  for  a  moment  to  allow  the  entrance  of  air 
through  possible  leaks.  On  releasing  it  the  piston  should  re- 
turn to  the  bottom  of  the  instrument.  (The  pistons  of 
syringes  made  entirely  of  glass  should  not  be  released  sud- 
denly, lest  their  impact  fracture  the  bottom  of  the  barrel.) 
Then  air  is  drawn  into  the  syringe,  the  tip  is  again  closed 

*  Stains  of  silver  nitrate  may  be  removed  from  the  hands  with  a 
strong  solution  of  potassium  iodid;  stains  of  iodin,  with  ammonia 
water;  and  stains  of  methylene  blue  or  other  anilin  dyes,  with  strong 
hydrochloric  acid. 


110 


_  The  Surgical  Assistant. 


with  a  finger,  and  pressure  is  made  on  the  piston  rod.  If  it 
yields,  the  syringe  is  defective.  The  tests  may  be  repeated, 
using  water  instead  of  air.  If  on  attempting  to  empty  the 
syringe  against  the  compressing  finger,  water  escapes  at  the 
bottom,  the  parts  of  the  frame  should  be  screwed  more 
tightly  together.  If  this  fails  to  prevent  the  leakage,  the  in- 
side washer  is  defective  or  out  of  position,  and  should  be  re- 
placed or  re-arranged.  If  the  fluid  in  a  syringe  escapes  above 
the  piston,  when  pressure  is  exerted  against  the  occluding 
finger,  the  piston  is  too  small. 

A  syringe  that  cannot  be  boiled,  once  used  in  aspirating  in- 
infected  tissues,  should  not  be  employed  for  injections — at 


Fig.  27.     Repairing  aspirating  syringe  with  leather  packing. 

least  not  until  all  its  parts  have  been  thoroughly  disinfected. 
Syringes  but  little  used  can  be  kept  in  good  order  by  occa- 
sionally rnQistening  the  w&sberg  and  packings  to  prevent 


Care  of  Instruments.  Ill 

shrinkage.  To  cleanse  or  repair  a  glass  and  metal  syringe 
with  leather  or  rubber  packings,  the  top  should  be  unscrewed 
and  the  piston  removed.  The  framework  and  barrel  are 
cleaned  with  soap  and  water  or  with  benzin  and  then  boiled, 
after  taking  out  the  washers.  In  most  syringes,  the  piston 
packing  can  be  regulated  in  size  by  means  of  the  nut  attached 
to  it.  If  it  be  of  leather  and  is  much  shrunken  it  should  be 
soaked  in  water,  but  only  long  enough  to  restore  it  to  the 
proper  size.  It  may  be  sterilized  by  immersion  in  2  per  cent, 
formaldehyd  solution.  The  piston  should  be  re-introduced 
sidewise  at  first,  and  with  a  rotary  motion.  Rubber  pack- 
ings require  lubrication  with  water  or,  if  this  is  insufficient, 
with  a  httle  tincture  of  green  soap  or  lysol.  If  the  piston 
is  of  leather  a  little  olive  oil  should  be  dropped  in  the  cell 
between  the  two  packings  usually  present,  just  as  the  second 
packing  is  about  to  be  pushed  into  the  barrel.  If  the  small 
(outside)  washer  at  the  needle  end  of  a  syringe  is  lost 
or  injured  during  an  operation  a  substitute  can  be  extem- 
porized by  winding  about  the  screw-thread  a  little  absorb- 
ent cotton. 

The  moisture  in  syringe  needles  after  use  should  be  blown 
out.  This  procedure  may  be  supplemented  by  warming  the 
needle  several  inches  above  a  flame.  The  wire  should  then  be 
dried  and  passed  through  the  needle.  If  the  lumen  of  the 
needle  is  found  occluded  by  a  plug  that  cannot  be  displaced 
with  the  wire  or  by  the  pressure  of  fluid  from  the  syringe, 
the  following  device  may  be  employed  :  Attached  to  a  syringe 
filled  with  water,  the  needle  is  held  in  an  alcohol  flame,  while 
pressure  is  exerted  on  the  piston.  When  the  needle  be- 
comes very  hot,  steam  and  water  will  suddenly  escape 
through  it.  This  procedure  should  be  used  as  a  last  resort, 
however,  for  it  injures  the  needle. 

Fountain  syringes  are  to  be  washed  out  and  suspended, 
bottom  up,  until  dry,  after  which  their  mouths  may  be 
plugged  with  absorbent  cotton  to  exclude  dust.  Potassium 
permanganate  adhering  to  glass  or  rubber  irrigating  reser- 
voirs is  easily  decolorized  by  oxalic  acid  solution. 

Catheters   and  bougies   should  be   cleaned   as   described 


112  The  Surgical  Assistant. 

on  page  104.  They  are  then  sealed  in  a  tube  of  formalin- 
glycerin,  or  are  dried  and  either  dusted  with  talcum  pow- 
der and  placed  in  a  box,  or  hung  in  a  catheter  jar  con- 
taining a  formalin  pastil.  This  last  method  probably  does 
not  in  itself  reliably  asepticize  catheters,  and  when  employed 
for  long  periods  it  allows  woven  instruments  to  deteri- 
orate. 

Rubber  bandages  (Martin's)  should  be  dusted  with  talcum 
and  rolled  up,  the  tape  end  innermost.  They  should  be 
wrapped  in  paper  or  gutta-percha,  and  enclosed  in  a  tin  box 
made  air-tight  by  means  of  a  strip  of  adhesive  plaster,  in  the 
same  way  that  a  plaster  of  Paris  bandage  is  preserved.  Con- 
strictors are  to  be  similarly  treated.  These  precautions  save 
the  rubber  from  drying  and  cracking. 

Rubber  gloves  are  dried  with  a  towel  and  dusted  with  tal- 
cum or  corn-starch,  then  turned  inside  out  and  dried  on  the 
other  surface.  The  glove  fingers  may  be  easily  reversed  by 
closing  the  opening  of  the  glove  at  the  wrist  with  a  few  turns 
of  the  rubber  and  by  pressing  the  air  thus  sealed  in  the  body 
of  the  glove  toward  the  fingers.  Punctures  and  small  tears 
are  patched  (all  on  the  same  side)  with  pieces  from  an  old 
glove,  by  means  of  india-rvibber  cement  thinned  out,  if  neces- 
sary, with  a  little  benzin.  Larger  rents  in  the  fingers  may  be 
covered  with  a  finger  cot  when  the  glove  is  worn.  Rubber 
gloves,  like  rubber  bandages,  should  be  kept  well  protected 
.from  the  air. 

Bandage  knives  cut  best  when  they  have  a  "  saw  edge." 
This  is  secured  by  sharpening  them  on  a  rough  stone,  such 
as  a  window  sill. 

The  mechanisms  of  electric  appliances  ought  to  be  studied 
and  tested  in  advance  of  an  operation.  The  poles  of  a  gal- 
vanic battery  should  be  lifted  from  the  cells  while  the  battery 
is  out  of  use.  It  need  hardly  be  emphasized  that  care  must 
be  exercised  not  to  spill  the  fluid.  With  dry  cell  batteries 
the  only  caution  necessary  is  to  see  that  the  circuit  is  open 
before  the  box  is  put  away.  Wet  electrodes  should  be 
wrapped  in  rubber  tissue  if  left  in  the  box.  Paquelin-  and 
galvano-cauteries  should  also  be  tested  before  an  operation  is 


Care  of  Instruments.  Il3 

begun.  The  tip  of  a  Paquelin  instrument  (appendix,  figure 
6)  should  be  removed  while  it  is  still  hot,  and  before  the  cur- 
rent of  benzin  vapor  has  been  turned  off,  for  incomplete  com- 
bustion of  the  vapor  appears  to  favor  clogging  of  the  sponge 
platinum. 


CHAPTER   VIIL 

HANDING  INSTRUMENTS. 

No  duty  that  an  assistant  can  assume  is  as  apt  to  tax  his 
forethought,  skill  and  patience  as  that  of  "  handing  instru- 
ments." He  must,  at  the  same  time,  deliver  what  is  needed 
at  the  moment,  cleanse  and  replace  appliances  that  have  been 
used,  and  be  ready  with  what  may  be  required  next.  If  he 
is  not  to  help  at  the  wound,  in  addition,  he  should  stand  as 
near  to  it  as  possible,  that  he  may  watch  every  step  in  the 
operation.  He  must  observe  closely  and  act  promptly.  // 
the  surgeon  works  rapidly  the  instrument  hander  must  think 
more  rapidly.  His  duty  is  to  anticipate  the  operator's  needs 
and  to  adapt  his  armamentarium  to  conditions  as  they  are 
developed.  That  assistant  is  useful  who  can,  at  each  step, 
place  the  appropriate  appliance  in  the  hands  of  the  operator, 
just  one  instant  before  the  latter  realizes  that  he  needs  it. 
Often  deeply  engrossed  in  the  study  of  the  condition  present, 
the  surgeon  will  be  grateful  for  the  suggestion,  when  there 
is  handed  to  him  at  the  right  moment  the  right  thing  with 
which  to  meet  that  condition. 

The  instrument  hander  should  therefore  think  out  in  ad- 
vance the  various  steps  of  the  operation  and  the  complications 
that  may  arise  at  each,  and  he  should  prepare  his  materials 
accordingly.  They  ought  to  be  arranged  conveniently  and 
systematically  on  his  table. 

Powder  sifters  (appendix,  fig.  7),  cautery  handles,  and 
other  unsterilized  articles  should  be  wrapped  in  pieces  of 
gauze  (which  may  be  held  in  place  with  a  bit  of  catgut  or  a 
safety-pin),  or  handled  with  towels,  and  jars  and  basins  that 
are  placed  near  the  instruments  should  be  surrounded  with 
towels  to  prevent  infection  of  tools  or  fingers  by  accidental 

114 


Arrangement  of  Instruments. 


115 


contact.  The  instruments  themselves  should  be  laid  out, 
as  nearly  as  possible,  in  the  order  in  which  they  will  be 
needed,  e.  g.,  for  a  laparotomy, — scalpels,  hemostatic  forceps, 
mouse-tooth  forceps,  scissors  (straight  and  curved),  retrac- 
tors (sharp  and  blunt),  etc.;  for  an  osteotomy, — scalpels, 
hemostats  (if  no  tourniquet  is  used),  retractors,  periosteal 
elevators,  raspatories,  chisels  and  mallet,  sharp  spoons,  etc. ; 
for  a  curettage  of  the  uterus, — speculum,  volsellum,  uterine 
sound,  dilators,  curettes,  intra-uterine  irrigating  tip,  dress- 


FlG.  17.  Instrument  table,  a,  sterilized  towels;  b,b.,  gauze  jars;  c,  sterile 
adhesive  strips  ;  d,  sterile  absorbent  cotton  ;  e,  dish  of  alcohol  for  prepared 
sutures  and  ligatures;  f,  dish  of  sublimate  solution,  one-fifth  per  cent.,  for 
ligatures  in  bottles  and  gutta-percha ;  g;  basin  with  sponge  for  cleansing  in- 
struments ;  h,  packings ;  /,  sterilized  safety-pins ;  /,  needles ;  k,  aspirating 
syringe  ;  /,  the  other  instruments  arranged  in  the  order  in  which  they  will  be 
needed  ;  m,  pads ;  w,  drainage  tubes. 


ing  forceps.  It  will  be  convenient  for  the  instrument  hander 
to  lay  aside  for  his  own  use  in  preparing  sutures,  packings 
and  the  like,  a  pair  of  straight  scissors,  a  pair  of  curved 
scissors,  a  pair  of  thumb  forceps  and,  if  the  sterilizer  is  kept 
at  hand,  a  pair  of  dressing  forceps  to  lift  instruments  out  of 
it.  Syringes  are  to  be  tested,  as  previously  described,  and 
the  adjustment  of  complicated  implements  carefully  in- 
spected. 
The  needles  are  spread  out  (dry,  gr  in  a  dish  of  alcohol), 


116  The  Surgical  Assistant. 

according  to  their  shapes  and  sizes,  so  that  at  any  moment 
an  appropriate  needle  may  be  quickly  selected.  Operators 
have  individual  fancies  in  the  use  of  needles  but,  in  a  general 
way,  it  may  be  stated  that  the  ordinary  curved  surgical  needle 
is  most  generally  useful,  that  needles  curved  in  a  half  circle 
are  well  adapted  for  deep  suturing  in  narrow  spaces  and  for 
passing  a  mass  ligature,  and  that  small  straight  needles  are  of 
great  service  in  intestinal  work.  The  Hagedorn  needle, 
which  is  flat  and  sharp  (  fashioned  at  the  point  somewhat  like 
a  half-spear-head)  and  has  a  large  eye,  is  given  the  prefer- 
ence by  many  surgeons.  It  is  used  with  a  Hagedorn  needle- 
holder,  or  passed  with  the  fingers  alone.  The  instrument 
hander  should  select  a  needle  strong  enough  for  the  tissues 
which  it  is  to  traverse,  but  otherwise  no  larger  than  is  neces- 
sary to  carry  the  suture.     See  appendix,  figure  27. 

If  suture  materials  are  brought  to  the  operation  in  bottles 
or  sealed  tubes,  these  may  be  sterilized  in  sublimate  solution, 
or  opened  in  a  towel  (the  tubes  are  to  be  broken)  and  the 
contents  dropped  into  a  dish  of  alcohol.  Spools  that  are 
mounted  in  wide-mouthed  jars  are,  of  course,  not  to  be  re- 
moved. With  these  the  free  end  of  the  silk  or  gut  should  be 
drawn  up  with  forceps,  and  as  much  as  is  needed  for  a  suture 
or  a  ligature  cut  off  about  an  inch  from  the  reel,  care  being 
taken  to  keep  the  material,  the  instruments  and  the  fingers 
from  contact  with  the  edge  of  the  jar.  A  supply  of  ligatures 
eight  to  nine  inches  in  length  should  be  prepared  in  advance. 
They  are  coiled  up,  ring-like,  by  wrapping  them  about  two 
fingers  of  the  left  band  {not  about  the  nails),  and  then  laid 
back  in  the  alcohol.  If  the  free  end  of  the  ligature  thus  coiled 
is  twisted  once  around  a  segment  of  the  ring,  it  will  prevent 
the  ligature  from  straightening  out  again  in  the  dish.  Catgut 
of  the  size  numbered  2  in  figure  28*  is  most  generally  useful 
for  ligatures,  but  number  i  may  be  used  in  delicate  plastic 
work,  as  on  the  face,  while  heavier  material  (number  4  to 

*  The  scales  of  numbers  employed  by  different  manufacturers  are 
not  identical.  The  ligature  numbers  referred  to  through  the  text 
are  intended  to  indicate  sizes  that  correspond  to  those  numbers  in 
figure  28. 


Ligatures. 


m 


number  6)  is  needed  for  large  pedicles  (as  of  the  renal  ves- 
sels) and  similar  "  mass  ligatures." 


Fig.  28.     Surgical  catgut— scale  of  sizes. 

Two,  at  least,  of  each  kind  of  suture  that  will  be  needed 
should  be  threaded  in  advance,  rolled  up  with  the  needle,  and 
placed  in  the  ligature  dish.     Sutures  of  the  size  correspond- 


ll^  The  Surgical  Assistant, 

ing  to  number  i  in  the  scale  here  given  will  be  most  often 
needed.  For  ophthalmic  operations  and  other  delicate  work, 
sutures  numbered  o  and  oo  will  be  useful,  while  the  indica- 
tions for  heavier  material  are  obvious.  Twisted  silk  is  most 
convenient  in  the  smaller  sizes,  braided  silk  in  the  larger 
ones.  In  general,  sutures  should  be  about  twelve  inches  long, 
depending  upon  the  length  of  the  wound  to  be  united  and  the 
manner  in  which  the  stitches  are  to  be  placed.  It  is  a  less 
serious  fault  to  cut  a  suture  rather  too  short  than  to  hand  one 
too  long,  for  long  threads  are  apt  to  drag  over  the  skin,  and 
are  awkward  to  manipulate. 

In  threading,  the  suture  should  be  held  close  to  its  end  be- 
tween the  right  thumb  and  forefinger,  the  needle,  correspond- 
ingly held  in  the  left  hand,  being  passed  over  it.     If  the 


Fig.  29.     Squeezing  end  of  catgut  for  insertion  in  eye  of  needle. 

needle-eye  rebels  against  the  passage  through  it  of  a 
piece  of  catgut  or  kangaroo  tendon,  the  difficulty  can  usually . 
be  overcome  by  cutting  the  end  of  the  suture  obliquely  and 
flattening  it  by  pressure  between  the  handles  of  the  scis- 
sors. Silk,  however,  should  be  cut  squarely  across,  lest  its 
strands  unravel  on  attempting  to  pass  it  through  the  eye. 
Small  sutures  are  apt  to  slip  out  of  the  needle  unless  fastened 
to  it  with  a  single  knot.  Silkworm-gut  is  secured  by  twist- 
ing it  several  times,  or  more  correctly,  by  twisting  the  needle 
on  its  long  axis  while  holding  the  loop  of  silkworm-gut 
steady.     Silver  wire  is  prevented  from  slipping  out  of  the 


Sutures. 


119 


needle  by  flattening  the  short  and  long  end  together  and, 
if  necessary,  by  twisting  them  slightly  on  each  other. 

"  Button  sutures,"  used  after  breast  amputations  or  laparo- 
tomies, when  there  is  great  tension  to  be  overcome,  are  to  be 
prepared  by  mounting  on  stout  silk,  or  on  one  or  two  strands 
of  silkworm-gut,  a  piece  of  block  tin  about  a  half  inch 
square,  and  a  large  lead  shot,  both  perforated.  The  corners 
of  the  tin  are  trimmed  to  protect  the  skin,  for  which  account 
the  sharp  edges  of  the  button  should  also  be  turned  up 


Fig.  30.    Twisting  silkworm-gut  suture. 


(towards  the  shot).  After  the  button  the  shot  is  slipped  on 
the  suture,  and  clamped  about  a  quarter  of  an  inch  from  the 
end  by  compression  with  a  needle-holder  or  other  heavy  in- 
strument. Instead  of  the  tin  and  shot,  an  ordinary  bone  or 
china  button  may  be  used,  two  strands  of  silk  or  silkworm-gut 
being  passed  through  its  holes  and  tied  together  on  its  con- 
pave  surface.    Buttons  of  all  kinds  are  apt  to  cause  pressure 


120 


The  Surgical  Assistant. 


necrosis  of  the  skin ;  for  them  may  be  substituted  small  rolls 
of  gauze  or  pieces  of  rubber  tubing,  over  which  the  suture 
ends  are  tied  (quilled  sutures). 

When  handmg  a  suture  to  the  operator  the  needle  should 
be  grasped  near  its  eye  in  the  holder,  the  point  of  the  needle 
should  be  to  the  operator's  left  and  its  concavity  towards  him. 
When  a  reversed  suture  is  to  be  passed  the  position  of  the 
needle  in  the  holder  is  to  be  reversed,  as  it  is  to  be,  also,  for 


Fig.  31.     '•  Button  suture." 


left-handed  operators.  If  the  needle-holder  has  a  tapering 
end,  only  flat  needles  should  be  grasped  near  its  extremity, 
for  curved  ones  are  apt  to  be  broken  by  the  narrow  tip.  With 
the  suture  should  be  handed  a  mouse-tooth  forceps,  and  a 
pair  of  curved  scissors.  With  "  button  sutures  "  should  also 
be  handed  a  hemostat,  to  secure  the  free  end  of  the  suture 
after  it  has  passed  through  the  tissues,  until  the  operator  is 


Drains  and  Packings. 


121 


ready  to  fix  it  permanently  with  a  second  button  and  shot. 
These  the  assistant  should  hold  to  him  in  the  palm  of  his 
hand,  and  should  pass  after  them  an  instrument  for  com- 
pressing the  shot.  Especial  care  should  be  exercised  that 
suture  ends  touch  nothing  but  the  assistant's  hand  in  transit 
from  instrument  table  to  operator. 

Some  at  least  of  the  gauze  drains  and  packings  that  will  be 
needed  should  be  prepared  in  advance.  It  is  well,  too,  to  pre- 
pare the  dressing  and  lay  it  aside,  covered  with  a  towel.  For 
mastoid  operations  slender  strips  of  gauze  will  sometimes  be 


Fig.  32.    Handing  gauze  packing. 


more  useful  than  sponges  for  cleaning  narrow  recesses.  For 
laparotomies,  several  packings  of  various  widths  and  appro- 
priate thicknesses  should  be  cut  and  kept  in  readiness  on  the 
instrument  table.  If  the  intestines  are  apt  to  be  much  ex- 
posed, hot  towels  and  pads  should  also  be  at  hand.    These  are 


122 


The  Surgical  Assistant. 


made  ready  when  needed,  by  folding  them  in  the  center  of  a 
towel,  which  is  to  be  dipped  into  a  basin  of  water  kept  hot 
over  a  small  flame.  The  towel  is  then  wrung  by  its  dry  ends, 
and  the  pad  is  lifted  out. 

Laparotomy  pads  should  be  handed  with  that  corner  up- 
permost to  which  is  usually  sewed  a  strand  of  stout  silk  for 
the  attachment  of  an  artery  clamp  to  be  left  hanging  outside 
the  belly.  With  pads  or  abdominal  packings  should  be 
handed,  for  their  introduction,  a  pair  of  blunt  scissors  curved 
on  the  flat,  or  a  similarly  shaped  instrument.     (Figure  32.) 

Split  compresses  are  made  by  dividing  folded  pieces  of 
gauze  half  way  through  their  middle.  They  are  useful  for 
surrounding  an  appendix  to  prevent  soiling  of  the  other 
tissues  when  it  is  amputated,  for  dressing  about  the  project- 
ing end  of  a  drainage  tube,  etc. 


Fig.  33.     Handing  "cigarette"  drain. 


The  Mikulicz  bag  consists  in  a  few  layers  of  gauze  which 
are  laid  flat  into  a  wound  {e.  g.,  after  nephrotomy)  and 
tucked  into  all  its  recesses.  The  edges  of  the  "  bag  "  project 
beyond  the  skin.  Packings  are  laid  in  the  wound  thus  lined 
with  gauze,  and  renewed  at  intervals,  the  bag-  itself  being  left 


Drains  and  Packings. 


123 


in  place  for  several  days  (usually  until  it  is  loosened  by 
wound  secretions). 

Gauze  drains  should  be  trimmed  evenly,  and  freed  of 
ravelled  strands.  The  cigarette  {or  Morris)  drain  consists 
in  a  wick  or  roll  of  gauze  of  appropriate  size,  wrapped  in 
gutta-percha  tissue.  The  free  edge  of  the  rubber  may  be 
fastened  down  by  slightly  moistening  it  with  chloroform. 
The  gauze  must  project  beyond  the  rubber  at  each  end.  This 
drain  combines  the  advantages  of  gauze  capillarity  with  the 
ease  of  removal  of  rubber  tubing.  It  is  introduced  with 
dressing  forceps  or  with  the  fingers. 

Drainage  tubes  should  be  cut  obliquely  at  the  deep  end,  and 
the  edge  of  this  cut  bevelled  with  curved  scissors.  Fenes- 
trae  may  be  cut  along  the  tube,  of  size  and  number  determined 
by  the  nature  and  quantity  of  the  discharge  to  be  drained. 


Fig.  34.    Preparation  of  drainage  tube. 

Two  medium-sized  tubes  drain  better  than  one  large  one, 
more  especially  since  they  afford  the  means  of  recurrent  irri- 
gation.   A  safety-pin  is  usually  fastened  through  the  project- 


FiG.  35.    Fenestrated  drainage  tube. 


ing  end  of  the  tube.  For  introduction  through  a  narrow  or 
an  irregular  tract,  the  tube  may  be  stretched  tightly  over  a 
large  probe,  the  tip  of  which  impinges  against  the  inside  of 


1S4 


The  Surgical  Assistant. 


the  rubber  near  the  end.  Traction  threads,  for  pulHng  tub- 
ing through  a  sinus,  or  attaching  tampons,  are  best  fastened 
by  a  clove  hitch  (the  manner  of  making  which  is  shown  in 
figure  37),  which  is  secure  but  easily  removable. 

The  preparation  of  the  tampon  camila  and  of  the  "  canule 


Fig.  36.    Handing  drainage  tube  on  probe. 


en  chemise  "  will  be  more  appropriately  described  in  discuss- 
ing assistance  at  rectal  operations. 

In  the  manner  of  passing  an  instrument,  there  is  an  art. 
Every  appliance  or  dressing  should  he  placed  in  the  grasp  of 
the  operator  in  the  direction  and  position  in  which  he  is  to 
apply  it  in  the  wound.    This  relieves  him  of  the  necessity  of 


Handing  Instruments. 


125 


lifting  his  eyes  from  the  operating  field  to  the  appliance,  and 
of  turning  the  latter  about  in  his  hand. 


a  Jb 

Fig.  37.    The  clove  hitch.    «,  formation;  b,  application. 

Beginning  with  the  scalpel,  the  blade  should  point  approxi- 


Fig.  38.    Incorrect  manner  of  handing  chisel  and  mallet  to  operator. 

mately  in  the  direction  of  the  wound  to  be  made,  when  it 
leaves  the  assistant's  hand.     Several  artery  forceps  should 


126 


The  Surgical  Assistant, 


be  laid  near-by  while  the  incision  is  in  progress,  and  the  han- 
dles should  point  towards  the  operator — or,  better,  some 
should  point  towards  the  operator,  and  some  towards  his 
assistant  at  the  wound.  (If  the  scalpel  used  for  the  skin  in- 
cision is  now  replaced  by  a  second  one,  the  chances  of  con- 
veying infection  into  the  wound  from  the  skin  are  thereby 
diminished.)  The  sharp  retractors  that  may  next  be  needed 
should  be  held  by  the  instrument  hander  by  their  shanks,  and 
the  handles  should  be  pointing  away  from  the  wound  and  at 


Fig.  39.    Correct  manner  of  handing  chisel  and  mallet,  suited  to  the  posi- 
tion of  the  operator  and  the  direction  of  the  wound. 


right  angles  to  its  axis.  So,  too,  with  the  mouse-tooth  for- 
ceps next  required.  One  should  be  held  within  easy  grasp 
of  the  operator,  the  other  in  the  position  in  which  his  assistant 
will  apply  it.  So,  too,  with  sutures,  the  instrument  passer 
should  place  the  needle  holder  with  his  left  hand  into  the 
right  hand  of  the  operator  and  the  forceps  with  his  right  hand 
into  the  surgeon's  left,    And  so,  too,  with  all  the  instru- 


Handing  Instruments. 


m 


ments  and  all  the  dressings,  even  down  to  so  small  an  article 
as  a  safety-pin. 

During  the  course  of  an  operation,  only  those  few  instru- 
ments in  immediate  use  should  be  left  on  the  patient's  body, 
or  on  the  "  invalid  table  "  over  his  body,  and  these  should  be 
cleaned  whenever  blood  accumulates  upon  them.  Others 
that  have  been  used  should  be  cleansed  and  replaced  on  the 
instrument  table  or,  if  they  have  been  soiled  by  infectious 


Fig.  40.    Handing  suture  and  forceps. 

material,  laid  apart  from  the  instruments  that  are  still  sterile. 
The  assistant  should  see  to  it  that  instruments  lying  on  the 
patient's  body  are  not  brought  in  contact  with  the  elbows  of 
the  operator,  that  the  sharp  points  of  tools  are  tarned  down- 
wards, and  that  the  towel  on  which  the  instruments  are  al- 
lowed to  lie  is  replaced  when  it  is  blood-soaked  or  otherwise 
soiled. 


128 


'i^HE  Surgical  Assistant 


The  assistant  zvho  hands  sponges  should  observe  the  same 
system.  She  must  watch  the  operation  closely  to  adapt  the 
sizes  of  the  sponges  to  the  needs  developed.  If  gauze 
"  wipes  "  are  used,  several  may  be  placed  near  the  wound, — 
by  means  of  a  pair  of  forceps  to  avoid  undue  handling.  If 
sea-sponges  are  being  employed  she  ought  to  have  a  clean  one 
always  in  her  hand,  ready  when  needed.  This  sponge  she 
passes  from  her  fingers  to  the  wound-assistant's  palm,  taking 
the  soiled  sponge  from  his  fingers  into  her  palm. 

The  soiled  sea-sponge  must  be  passed  through  two  basins 
of  cleansing  solution,  then  squeezed  thoroughly.  ,When  the 
sponging  is  active  it  is  well  to  have  one  or  two  sponges  lying 
near  the  field  of  operation,  for  nothing  is  more  annoying  than 
to  have  to  wait  for  a  fresh  sponge — except,  perhaps,  to  be 
obliged  to  wipe  a  wound  with  a  sponge  already  soaked  with 
blood. 

Cotton  sponges,  little  used  except  in  minor  surgery  and 
for  ophthalmic  work  and  wound-dressings,  may  be  neatly 
made  from  squares  of  absorbent  cotton.     The  edges  of  these 


Fig.  41.     Cotton  sponges. 


may  be  twisted  together,  thus  making  a  loose  ball.  A  better 
method,  but  one  requiring  a  little  more  dexterity,  is  the  fol- 
lowing: The  left  hand  is  made  into  a  loose  fist,  and  the  square 
of  cotton  is  laid  on  the  thumb  and  fore-finger.     In  the  centre 


Handing  Instruments.  120 

of  the  square  is  placed  a  smaller  bit  of  cotton  to  make  the 
sponge  more  solid.  With  the  index  finger  of  the  other  hand, 
the  edges  of  the  cotton  are  turned  in ;  then  this  finger  is  held 
in  the  centre  of  the  sponge,  which  is  rotated  about  it  with  the 
left  hand  to  make  the  ball  compact. 

Sponge  holders  and  applicators,  like  other  instruments, 
should  be  passed  in  the  proper  direction.  Thus,  for  spong- 
ing in  the  depth  of  the  abdomen  the  sponge-holder  is  handed 
vertical,  the  sponge  downward;  for  sponging  in  the  vagina, 
the  holder  is  handed  horizontal,  the  sponge  forward.  It  is 
important  that  sponges  should  be  fastened  compactly  and 
firmly  in  their  holders,  and  that  cotton  should  be  firm  on  ap- 
plicators. Applicators  with  square  ends  are  better  than 
those  with  corrugated  or  spiral  ones,  for  they  hold  the  cotton 
securely  yet  allow  of  its  easy  deliberate  removal.  The  wind- 
ing of  cotton  about  an  applicator  should  begin  furthest  from 
the  tip,  and  here  the  cotton,  small  in  amount,  must  be 
pressed  firmly  between  thumb  and  finger.  As  the  tip  is 
brought  down  through  the  fingers  the  pressure  is  lessened, 
making  the  cotton  here  less  firm  but  thicker  and  more  ab- 
sorbent. 

Nitrate  of  silver  may  be  attached  to  a  probe  or  applicator 
in  full  strength,  for  use  in  the  middle  ear,  etc.,  by  heating  the 
tip  of  the  instrument  in  a  flame  and  pressing  it  into  the  solid 
caustic.  This  melts  a  little  of  the  salt,  which  on  cooling 
forms  a  bead  on  the  probe.  For  use  in  more  accessible  situa- 
tions the  nitrate  of  silver  cone  may  be  conveniently  mounted 
in  a  discarded  thermometer  case  by  means  of  a  little  paraffin 
or  of  a  strip  of  adhesive  plaster. 


CHAPTER  IX. 
ASSISTANCE  AT  THE  WOUND. 

In  the  immediate  assistance  in  an  operation,  close  attention 
and  manual  gracefulness  are  far  more  to  be  cultivated  than 
the  display  of  mere  brilliancy  of  technic.  Only  by  strict 
attention  can  the  assistant  supply  the  needs  of  the  moment 
and  foresee  the  requirements  that  will  next  develop.  He 
should  be  always  ready  to  do  his  share,  undirected ;  he  should 
not  try  to  do  more  than  his  share.  At  each  step  of  an  opera- 
tion he  should  be  close  at  hand,  yet  never  in  the  way — "  al- 
ways there,"  but  never  "  too  much  there."  How  many  of 
the  manipulative  details  he  may  undertake  himself  must  de- 
pend upon  his  own  technical  experience  and  upon  his  famil- 
•iarity  with  the  surgeon's  methods.  An  ill-considered  act 
may  spoil  an  hour's  work ;  on  the  other  hand,  a  quick  move- 
ment— likewise  unsolicited — may  save  a  patient's  life.  What- 
ever the  assistant  does,  he  should  do  quietly,  without  disturb- 
ing the  operator  and,  if  possible,  without  waiting  for  him  to 
give  orders.  If  all  the  assistants  are  thus  quick,  and  suf- 
ficiently familiar  with  the  technics  of  the  procedure  at  hand, 
and  with  those  of  the  individual  surgeon,  a  long  and  compli- 
cated operation  can  he,  and  should  be,  conducted  from 
beginning  to  end  without  a  ivord  being  spoken. 

The  surgical  assistant  must  work  unobtrusively,  and  a 
primary  principle  of  his  art  is,  that  his  every  move  must  be 
directed  by  a  consideration  of  the  convenience  of  the  surgeon. 
He  will  hardly  allow  himself  to  interfere  with  the  operator's 
line  of  vision  or  to  obstruct  his  light  if  he  bear  in  mind  that 
the  dispatch  with  which  an  operation  can  be  carried  out  de- 
pends much  upon  the  manner  in  which  the  assistant  disposes 
his  body,  as  well  as  that  in  which  he  employs  his  hands. 

Dexterity  in  the  proper  use  of  the  hands  implies  also  the 
use  of  the  proper  hand.     Nothing  can  contribute  more  to 

130 


The  Incision. 


131 


the  graceful  conduct  of  an  operation  and  to  the  serenity  of 
the  operator,  than  careful  regard  to  this  apparently  small 


Pig.  i2.    Incorrect  manner  of  holding  retractors;  assistant's  left  forearm 
interferes  with  operator's  movements. 

matter.  In  manipulations  through  the  vagina  especially, 
where  the  field  is  relatively  small  and  the  number  of  instru- 
ments in  use  is  apt  to  be  large,  awkwardness  in  the  position 
of  the  assistant's  arm  or  in  the  assignment  of  his  work  to  one 
or  the  other  hand,  is  often  the  cause  of  annoyance  and  of  de- 
lay. 


Fig.  43.    Proper  disposition  of  hands  and  arms  in  manipulating  retractors. 

The  Incision  may  be  facilitated  by  aiding  the  operator  in 
stretching  the  skin.     This  is  done  with  the  left  hands  and  in 


132 


The  Surgical  Assistant. 


a  direction  at  right  angles  to  the  proposed  Hne  of  incision, 
the  assistant's  right  hand  holding  a  sponge  in  readiness  to 
dry  the  wound.  A  long  incision  through  a  loose  fold  of  skin, 
as  of  the  scrotum,  may  be  accomplished  by  a  short  downward 
sweep  of  the  knife,  if  the  tissue  is  pinched  up  on  each  side 
with  the  thumb  and  forefinger. 

Sponging  is  perhaps  more  than  any  other  one  thing  dur- 
ing an  operation,  what  most  requires  the  employment  of  a 


Fig.  44.    Stretching  the  skin  to  facilitate  primary  incision. 


diligent  assistant.  The  wound  must  be  kept  dry  at  all  times. 
To  accomplish  the  best  result  with  the  least  interference  to 
the  operator  the  sponge  should  be  used  frequently,  in  the 
short  intervals  between  the  operator's  manipulations,  with  a 
quick,  wiping  movement,  and  quickly  withdrawn  from  the 
line  of  vision.  To  remove  fluids  from  the  abdominal  or  other 
cavity,  a  rotary  motion  should  be  imparted  to  the  sponge — 


Sponging;  Retracting.  133 

especially  useful  if  the  fluid  is  thick  and  viscid.  To  prevent 
soiling  of  the  abdominal  contents  with  pus  or  feces  escaping 
from  a  small  opening,  bits  of  sea-sponge  should  be  used, 
either  prepared  on  artery  forceps  or  lifted  from  a  dish,  one 
by  one,  with  thumb  forceps.  The  manner  of  passing  and 
cleansing  sea-sponges  has  been  described.  Sponges  soaked 
with  pus  or  other  infectious  material  should  be  discarded  at 
once,  not  cleansed.  Obscuration  of  a  wound  by  the  oozing 
of  blood  from  one  angle  may  often  be  quickly  obviated  by 
pressing  a  sponge  or  a  bit  of  gauze  into  that  angle. 
A  few  rules  are  worth  remembering : 

Hold  the  sponging  hand  near  the  wound;  not  over  the 
wound. 

Keep  the  wound  dry ;  sponge  quickly  and  often. 
Use  dry  sponges ;  have  fresh  sponges  within  reach. 
Wipe;  don't  dip. 

Don't  sponge  against  the  operator's  knife  or  needle-point. 
Sponge  from  the  ivound  towards  the  skin :  never  from  the 
skin  into  the  wound. 

Never  use  in  a  clean  wound  a  sponge  that  has  been  on  the 
skin  or  in  contact  with  infectious  material ;  discard  it  at  once. 
Retracting.  Next  to  assiduous  sponging,  the  intelligent 
use  of  retractors  is  most  helpful  in  the  facilitation  of  an  oper- 
ation. Their  purposes  are  two-fold — to  expose  and  to  pro- 
tect. They  should  be  so  placed  as  to  best  display  the  tissues 
under  immediate  manipulation — usually  in  a  direction  at 
right  angles  to  the  wound,  or  in  the  angles  of  the  wound. 
They  should  be  inserted  carefully  and  deliberately,  never 
blindly  or  hastily,  lest  they  cause  laceration  or  mangling,  or 
push  from  view  structures  that  ought  to  be  exposed.  In  re- 
tracting an  abdominal  wound,  especially,  great  care  should 
be  exercised  to  avoid  including  the  intestine  in  the  grip  of 
the  instrument.  Traction  force  should  be  exerted  gently  and 
steadily— enough  to  satisfactorily  open  the  wound,  but  not 
enough  to  bruise  the  tissues.  When  using  sharp  retractors 
all  the  prongs  should  be  sufficiently  buried  to  prevent  slipping 
and  to  avoid  injury  to  the  surgeon's  fingers ;  but  if  the  super- 
ficial tissues  are  being  retracted,  the  assistant  should  see  that 


134 


The  Surgical  Assistant. 


the  prongs  are  not  forced  through  the  skin  from  beneath.  As 
the  dissection  or  other  manipulation  proceeds  deeper  and 
deeper  or  from  one  place  to  another,  so  the  retractors  should 
be  shifted — a  process  that  again  should  be  conducted  with 
due  regard  to  the  operator's  fingers.  ^Whenever  expedient, 
it  is  best  to  insert  a  second  retractor  in  the  new  site  before 
removing  the  first  retractor  from  the  abandoned  position. 
When  a  retractor  is  no  longer  serving  a  useful  purpose  it 
should  be  removed ;  but  if  the  assistant  is  in  doubt  as  to  its 
continued  utility  he  had  better  leave  it  in  position  until 
directed  otherwise.  In  any  case,  a  sharp  instrument  should 
not  be  withdrawn  from  beneath  the  operator's  hand  or  fore- 
arm. 


Fig.  45.    Use  of   retractors  to  expose  to    view    a  large  visceral   surface 
through  a  relatively  small  opening. 

The  assistant  should  early  learn  the  value  of  lifting  up 
with  the  retractors.     During  laparotomies,  especially,  this 


Dissection.  135 

simple  procedure  is  of  invaluable  aid,  in  separating  and  dis- 
playing the  various  layers  of  the  abdominal  wall  and  their 
bloodvessels  and  nerves,  in  drawing  the  parietal  peritoneum 
from  the  viscera  beneath,  and  in  exposing  the  abdominal  con- 
tents to  visual  exploration  through  a  relatively  small  opening. 
All  other  things  being  equal,  blunt  retractors  should  be  given 
the  preference  for  use  in  the  neighborhood  of  large  blood- 
vessels and  of  intestinal  or  other  delicate  structures.  Well- 
curved  blunt  hooks  and  blunt  retractors  should  be  chosen  for 
distracting  a  nerve  or  bloodvessel  or  a  tense  muscle  (e.  g., 
the  rectus  abdominis).  Obviously,  a  retractor  should  be 
selected  with  reference  to  the  size  and  depth  of  the  wound, 
for  its  purpose  is  to  create  space,  not  to  obstruct  it. 

Blunt  curved  scissors  are  useful  for  temporary  retraction. 
The  assistant's  fingers  may  be  similarly  called  into  requisi- 
tion, but  they  should  be  thus  employed  only  when  no  instru- 
ment at  hand  will  equally  serve  the  purpose. 

An  assistant  whose  sole  duty  may  be  to  hold  a  retractor  for 
even  an  hour  or  more,  should  not  allow  himself  to  become 
listless  and  to  loll  over  the  table  or  to  bear  his  weight  upon 
the  instrument,  for  aside  from  the  fact  that  this  is  inelegant 
and  indecorous,  prolonged  pressure  upon  the  patient's  skin 
by  the  shank  of  a  retractor  is  apt  to  cause  troublesome 
necrosis. 

Dissection.  The  character  of  the  assistance  required  in 
this  procedure  is  indicated  by  the  manipulations  of  the  opera- 
tor. Dissection  conducted  layer  by  layer  between  two  mouse- 
tooth  forceps  requires  of  the  assistant  to  seize  the  same  tis- 
sue as  does  the  operator,  near  to,  and  directly  opposite,  the 
point  where  he  attaches  his  forceps.  The  structure  grasped 
is  then  drawn  up,  allowing  the  passage  of  scalpel  or  scissors 
between  the  two  instruments.  Only  the  tissue  to  be  divided 
should  be  seized — obviously  a  very  important  consideration 
in  incising  the  parietal  peritoneum.  The  assistant  should 
not,  as  a  general  rule,  relinquish  his  grasp  until  the  operator 
has  removed  his  forceps  to  another  position,  when  the  as- 
sistant follows  him  thereto.  For  seizing  a  bloodvessel,  to 
dissect  it  from  its  bed,  anatomical  forceps  should  replace 


136 


The  Surgical  Assistant. 


toothed  instruments.     Either  hand  may  be  used  for  the  for- 
ceps, the  other  one  holding  a  retractor  or  a  sponge. 


Fig.  46.    Dissection  between  mouse-tooth  forceps. 

Hemostasis.  We  have  said  that  the  most  useful  service 
an  assistant  at  the  wound  can  perform  is  assiduous  and  in- 
telligent sponging.  When  divided  vessels  are  to  be  clamped 
it  is  especially  important  that  he  sponge  the  bleeding  surface 
in  order  that  the  exact  location  of  the  hemorrhage  may  be 
seen.  A  stream  of  blood  from  a  single  large  vessel  should  be 
stopped  at  once  by  the  assistant's  finger,  until  the  surgeon 
has  properly  exposed  the  vessel  for  clamping. 

If  there  is  simultaneous  bleeding  from  several  points,  as 
there  usually  is  after  a  long  incision,  the  assistant  may  take 
part  in  the  application  of  hemostats.  This  he  should  do  de- 
liberately, however  quickly,  taking  care  to  secure  in  the  grasp 
of  the  instrument  as  little  as  possible  of  the  tissue  surround- 
ing the  mouth  of  the  bleeding  vessel.  ^When  there  has  been 
exposed  a  vessel  that  must  be  "  Heated  in  continuity,  "  whil? 


Hemostasis.  137 

the  surgeon  clamps  it  at  one  end  the  assistant  clamps  it  at 
the  other ;  and  here,  too,  he  must  be  careful  to  catch  in  the 
forceps  no  nerve  or  other  structure  that  it  is  desirable  to  pre- 
serve. When  securing  a  vein  in  continuity  it  is  well  to  grasp 
it  proximally  first,  lest  otherwise  it  collapse  and  become  lost 
to  view.  An  inadvertent  nick  in  the  side  of  a  large  vein  is 
to  be  closed  with  a  small  "  bite  "  of  the  hemostat,  thus  allow- 
ing the  application  of  a  "  side  ligature." 

When  the  number  of  hemostats  applied  to  the  wound  is 
large  enough  to  obstruct  manipulations,  or  when  the  supply 
of  these  instruments  is  nearly,  but  not  entirely  exhausted, 
some  or  all  of  them  may  be  removed.  Small  vessels,  e.  g., 
many  of  those  in  the  skin,  are  usually  definitively  closed  by 
the  mere  pressure  of  the  forceps  for  several  minutes,  and 
slightly  larger  vessels  may  be  closed  by  twisting  the  forceps 
a  few  turns  before  removing  them ;  but  vessels  of  any  con- 
siderable size  are  to  be  tied  before  the  hemostats  are  with- 
drawn. Several  ligatures  may  be  applied  in  a  short  space  of 
time  if  the  assistant  afifords  intelligent  aid.  He  should  lift 
up  each  hemostat  in  turn  in  order  that  the  ligature  may  be 
passed  behind  it,  so  holding  the  forceps  that  the  tissues  to 
which  it  is  applied  are  not  twisted  or  distorted.  After  the 
ligature  is  passed  behind  it  the  handle  of  the  forceps  is 
dropped  or  depressed,  in  order  to  Hft  up  the  point  of  the  in- 
strument beyond  the  ligating  loop.  If,  however,  the  forceps' 
beak  is  too  deeply  buried  in  the  tissues  to  accomplish  this, 
the  assistant  should  draw  gently  upward  on  the  hemostat 
while  a  single  knot  is  formed  loosely  about  it.  The  loop  of 
catgut  can  then  usually  be  helped  to  slide  over  the  beak  if  the 
hemostat  is  rotated  slightly  from  side  to  side.  Sometimes, 
however,  the  surgeon  or  the  assistant  will  be  obliged  to  push 
the  loop  down  with  a  finger  or  with  an  instrument.  If  it  has 
not  been  thus  necessary  to  hold  the  forceps  up  while  the  first 
knot  is  tied,  the  assistant  should  seize  it  again  immediately 
thereafter,  in  order  to  remove  it  when  the  knot  is  complete. 
Occasionally  it  is  useful,  when  working  in  a  small  space,  to 
remove  the  clamp  after  the  first  knot  is  secured.  While  the 
e^ssistant's  left  hand  is  thus  occupied  with  the  manipulatioti 


138  The  Surgical  Assistant. 

of  the  hemostat,  his  right  should  hold  in  readiness  a  pair  of 
scissors  to  cut  the  ligature  ends.  Blunt-end  scissors,  curved 
on  the  flat,  are  best  adapted  to  this  purpose.  They  should  be 
held,  with  the  concavity  of  the  curve  uppermost,  by  the  ter- 
minal phalanx  of  the  thumb  and  the  middle  phalanx  of  the 
fourth  (or  third)  finger.  Downward  pressure  with  the 
thumb  and  upward  pressure  with  the  fourth  finger  secure 
close  contact  of  the  edges  when  cutting,  while  counter-pres- 
sure of  the  index  finger  over  the  lock  steadies  the  instrument. 


Fig.  47.  Manipulation  of  hemostat  and  scissors  in  the  application  of  a 
ligature. 

The  fifth  finger  may  be  rested  on  the  patient's  body  to  bal- 
ance the  hand.  The  scissors  are  held  slightly  open  while  the 
ligature  is  being  tied,  and  when  the  surgeon  lifts  its  free 
ends,  the  blades  are  made  to  surround  them.  With  a  quick 
movement  at  the  wrist  the  blades  are  to  be  carried  down 
along  the  strands  and  closed  about  a  quarter  of  an  inch  from 
the  knot.  These  manipulations,  longer  in  the  description 
than  in  the  performance,  secure  speed  as  well  as  precision. 

The  assistant  is  often  called  upon  to  apply  ligatures  him- 
self. The  "  square,  "  "  flat,  "  or  "  reef  "  knot  is  formed  by 
passing  one  end  of  the  ligature,  e.  g.,  that  in  the  right  hand, 
in  front  of  and  around  the  other  end  into  the  left  hand,  and 
tightening  the  first  knot ;  then  passing  the  same  ligature  end 
back  from  the  left  hand  in  front  of  and  around  the  other  end, 
as  before,  into  the  right  hand,  and  tightening  the  second  knot. 


Hemostasis. 


139 


If  the  second  loop  is  made  by  passing  the  ligature  end  in  a 
manner  different  from  that  in  which  it  was  passed  in  the 
first  loop  (i.  e.,  behind,  instead  of  in  front,  of  the  other 
strand),  there  is  formed  a  "  granny  knot.  "     Such  a  knot  is 


,^''^^'''*^ 


^!«!» 


Fig.  48.    Surgeon's  Knot. 
Flat  Knot. 
Granny  Knot. 


more  likely  to  slip  than  a  square  knot,  but  while  its  inadvert- 
ent application  is  a  surgical  inelegance  it  need  ordinarily 
cause  the  assistant  no  worry,  when  only  a  small  vessel  is 
concerned,  provided  that  it  has  been  drawn  tightly. 

The  "  surgeon's  knot  "  differs  from  the  square  knot,  in 
that  the  first  loop  is  made  by  carrying  one  end  of  the  ligature 
twice  around  the  other  end.  This  loop,  when  tightened,  is 
less  apt  to  slip  during  the  formation  of  the  second  one 
than  is  the  first  loop  of  the  square  knot,  which  latter  is  quite 
sufficient,  however,  for  most  of  the  bloodvessels  to  be  tied. 
A  third  loop  may  be  added  when  in  doubt  as  to  the  security 
of  the  second  one. 


140  The  Surgical  AssisxANt. 

"  Mass  ligatures  "  are  applied  in  the  same  manner,  but  it 
must  be  remembered  that  it  is  unsafe  to  tie  many  vessels  in 
one  mass.  If  the  surgeon  employs  a  "  Staffordshire  knot " 
to  secure  a  pedicle,  (usually  an  ovarian  pedicle),  the  assistant 
should  grasp  the  loop  of  silk  after  it  has  been  thrust  through, 
and  draw  it  over  the  ovary  or  other  mass  and  over  one  of  the 
two  free  ends  of  the  ligature,  which  are  then  tied  together 
after  drawing  them  tightly  to  constrict  the  pedicle  with  the 
loop.  Rubber  ligatures,  as  applied  to  the  renal  vessels  in 
nephrectomy,  are  secured  by  tying  a  strand  of  stout  silk  firmly 
about  a  single  knot  of  the  rubber,  tightly  drawn.  Pedicle 
ligatures  should  not  be  cut  shorter  than  half  an  inch  from. 
the  knot.  Whatever  the  size  of  the  mass  to  be  secured,  it  is 
worse  than  foolish  to  tighten  any  ligature  by  seizing  its  ends 
in  the  whole  hands  and  pulling  these  far  apart,  for  such  a 
procedure  will  cut  through  almost  any  ligature  (to  say  little 
of  the  assistant's  hands  themselves).  It  is  far  better  to  seize 
the  ligature  ends  between  the  thumb  and  forefinger  of  each 
hand,  and  bringing  the  tips  of  these  close  to  the  knot  and  to 
each  other,  thumb  nail  to  thumb  nail  or  finger  nail  to  finger 
nail,  to  exert  a  steady  traction  or  a  series  of  tractions. 

Assistance  in  applying  the  "  chain  ligature,  "  as  used,  for 
example,  upon  the  omentum,  is  rendered  in  the  following 
way :  The  tissue  is  lifted  up  and  spread  out  evenly  in  an 
assistant's  hands.  When  the  operator  thrusts  through  the 
omentum  at  a  point  near  its  edge  (determined  by  the  number 
and  position  of  the  bloodvessels)  a  pair  of  dressing-,  or  ana- 
tomical-, forceps,  the  assistant  inserts  in  its  beak  the  ends  of 
two  stout  (catgut)  ligatures,  which  are  dravv^n  through,  and 
the  corresponding  ends  of  one  of  these  (easily  determined 
by  a  seesaw  motion  on  the  strands)  are  tied  tightly  around 
the  free  edge  of  the  omentum.  Then  when  the  operator 
again  transfixes  the  tissue  the  assistant  places  in  the  forceps 
a  third  ligature  and  "  his  end  "  of  the  second  one.  After  the 
second  strand  is  tied  and  the  omentum  again  pierced,  the  sur- 
geon receives  from  the  assistant  a  fourth  ligature  and  the 
other  end  of  the  third  one,  and  so  on.  When  the  ligatures 
are  all  tied  they  are  to  be  lifted  up  in  a  row,  to  indicate  the 


Suturing. 


141 


line  of  amputation,  after  the  performance  of  which  their  free 
ends  are  to  be  cut. 


Fig.  49.    Application  of  "  chain  ligature  "  to  omentum. 


Suturing.  The  assistance  to  be  rendered  during  sutur- 
ing consists  in  exposing  the  edges  to  be  united  and  in  secur- 
ing their  accurate  coaptation.  When  it  is  convenient  to  do 
so,  it  is  helpful  to  lift  up  the  two  edges,  and,  if  they  be  of  the 
skin  or  muscular  aponeuroses,  to  put  them  more  or  less  upon 
the  stretch.  This  is  not  always  possible  with  deep-seated 
structures,  e.  g.,  the  peritoneum,  and  when  it  is  not  the  assist- 
ant must  content  himself  with  lifting  with  his  forceps  the 
exact  bit  of  tissue  through  which  the  needle  is  to  pass,  or 
exposing  it  so  that  the  operator  can  lift  it  up.  When,  how- 
ever, the  edges  can  be  stretched  this  may  be  done  by  inserting 
a  small  hook  in  each  angle  of  the  wound,  or  by  pinching  up 
both  edges  at  the  angles  with  mouse-tooth  forceps.  After  the 
first  knot  of  an  interrupted  or  continuous  suture  has  been 
secured  at  one  end  of  the  wound  the  end  of  the  suture  be- 
yond the  knot  may  be  drawn  up  as  a  guy-thread,  and  the 
hook  or  forceps  abandoned.  When  interrupted  sutures  are 
being  inserted  in  tissues  under  tension  the  margins  to  be 


142 


The  Surgical  Assistant, 


united  should  be  held  together  with  forceps  by  the  assistant 
as  each  knot  is  being  tied.    After  tying,  the  suture  may  be  cut 


Fig.  50.     Coaptation  of  edges  by  traction  wit-h  tenacula. 

short,  or  one  or  both  ends  "  cut  long,"  and  drawn  up  with  the 


Fig.  51.    Coaptation  of  edges  by  traction  with  two  forceps. 

first  one  in  an  assistant's  hand  until  all  the  sutures  of  that 
row  are  in  place.    The  adaptation  of  edges  during  the  intro- 


Suturing.  143 

duction  of  a  continuous  suture  is  maintained  by  the  assistant 
by  holding  taut  the  proximal  (loose)  end  of  the  thread  near 
its  emergence  from  the  tissues, — releasing  it,  to  secure  a  new 
hold,  as  the  next  suture  is  drawn  down  upon  the  line  of  union 
(Fig.  52).  The  final  knot  of  a  continuous  suture  is  made 
by  leaving  the  last  loop  only  partly  drawn  through  and  tying 
to  it  the  emergent  end  of  the  suture,  still  attached  to  the 
needle;  or,  by  drawing  the  final  loop  tightly  but  double,  the 
free  end  on  one  side  being  then  tied  to  the  double  (needle) 


Fig.  53.    Assistant's  manipulations  during  introduction  of  continuous  suture. 

end  on  the  other.  When  the  suture  has  been  secured  the  ends 
should  be  cut  short  and  the  needle  replaced  upon  the  instru- 
ment table  or  left  elsewhere  within  plain  view.  Skin  edges 
may  frequently  be  sufficiently  adapted  during  suturing,  with 
a  single  pair  of  forceps  (Fig.  53),  and  looser  folds  of  skin 
may  be  pinched  together  by  the  assistant's  fingers,  at  each 
end  of  the  wound,  a  continuous  suture  holding  well  enough 
in  place  when  there  is  no  tension. 

To  prevent  inversion  and  overlapping,  skin  edges  should 
be  carefully  coaptated  by  the  assistant.  This  is  to  be  done  by 
means  of  mouse-tooth  forceps,  everting  the  edges  of  the 
wound  as  they  are  brought  together  (Fig.  54).  It  should 
be  remembered  by  the  assistant,  when  he  applies  sutures  him- 
self, that  the  further  from  the  edges  they  are  inserted  the 
more  the  latter  are  inverted ;  and  that  by  shifting  the  inser- 


144 


The  Surgical  Assistant. 


tion  to  the  skin  edge  itself,  or  far  from  the  edge,  he  can  over- 
come a  tendency  to  inversion  or  eversion,  respectively. 
Sutures  that  he  applies  in  fascia  should  not  be  close  together 
nor  very  tightly  drawn,  lest  they  cause  necrosis. 


Fig.  53.    Lifting  skin  edges  with  one  forceps  for  introduction  of  suture. 


The  special  assistance  needed  in  the  application  of  button, 
shot  and  quilled  sutures  has  already  been  described 
(page  119). 

Removing  Sutures.  The  suture  is  lifted  up  with  forceps 
on  one  side  at,  or  near,  the  knot,  in  a  manner  to  drag  out  of 
the  skin  on  that  side  a  short  segment  of  the  loop  that  was 
buried  in  it.  With  scissors  this  freshly  exposed  segment  is 
divided  close  to  the  skin  itself.  By  this  manipulation,  when 
the  suture  is  lifted  out,  its  track  is  not  infected  by  pulling 
through  it  any  of  the  unburied  portion  of  the  loop. 

Irrigating.  Even  though  the  tubing  of  the  fountain 
syringe  or  irrigating  jar  is  sterilized  before  the  operation,  it 


Irrigatincj,  ^  145 

is  difficult  to  keep  it  so  for  any  length  of  time  and,  therefore, 


Fig.  54.    Eversion  of  wound  edges  during  suturing. 


Fig.  55.    Tying  button  sutures. 

if  the  assistant  himself  will  be  called  upon  to  irrigate,  he 


146  The  Surgical  Assistant. 

should  have  ready  a  separate  irrigating  tip  and  short  seg- 
ment of  rubber  tubing.  This  he  attaches  to  the  longer 
tubing  whenever  he  needs  it,  and  removes  it  immediately 
after. 

The  fluid  to  be  prepared  will  depend  upon  the  needs  of  the 
case.  Thus,  it  may  be  water,  saline  solution,  strong  or  weak 
sublimate  solution,  etc.  The  manner  of  irrigating  also  must 
be  varied.  If  its  purpose  is  simply  to  keep  the  operating  field 
clear,  as  in  plastic  operations  upon  the  perineum,  the  tip  is 
held  just  above,  but  close  to  the  wound,  and  a  short  stream, 
under  slight  pressure,  is  intermittently  discharged.  When  a 
cavity  is  to  be  washed  out,  however,  the  irrigation  should  be 
continuous  and  more  or  less  forcible,  but  so  directed  that  it 
produces  no  splashing.  The  force  of  the  stream  is  regulated 
by  the  height  of  the  reservoir,  and  may  be  further  varied 
by  pressing  upon  the  rubber  tube  with  the  fingers  or  with  a 
pinch-cock.  To  irrigate  the  abdominal  cavity,  the  saline 
solution  should  be  poured  from  a  pitcher. 


CHAPTER  X 
IMMEDIATE  POST-OPERATIVE  CARE  OF  THE  PATIENT. 

As  soon  as  an  operation  is  concluded  and  the  dressing  is 
applied,  the  patient's  shirt  should  be  drawn  down  and  a  blan- 
ket wrapped  about  him.  If,  in  spite  of  the  precautions  noted 
on  page  69,  the  shirt  has  been  much  wet  during  the  opera- 
tion, it  should  be  replaced  by  a  fresh  one  on  the  table,  to 
avoid  chilling  of  the  patient  and  soiling  of  the  bedclothes. 
To  put  a  nightshirt  on  an  unconscious' subject  is  facilitated 
by  employing  a  little  system.  After  the  soiled  shirt  is  drawn 
over  the  head  and  the  skin  is  thoroughly  dried,  one  of  the 
patient's  arms  is  pulled  through  a  sleeve  of  the  clean  shirt, 
the  body  of  the  garment,  rolled  up,  is  drawn  over  his  head, 
the  other  sleeve  is  adjusted,  and  then  the  shirt  is  pulled  down 
over  the  trunk.  If  the  patient  is  very  heavy,  it  may  be  neces- 
sary to  split  the  shirt  through  the  back  and  put  it  on  in  the 
manner  in  which  the  surgeon  dons  his  gown.  When  the 
patient's  condition  forbids  the  delay  and  exposure  incident  to 
a  change  of  garments,  he  should  simply  be  wrapped  in  a 
blanket,  and  thus  carried  to  bed. 

The  transportation  from  table  to  bed  is  conducted  on  a 
stretcher — for  which  an  ironing-board  may  be  made  to  serve 
— or  in  the  manner,  and  with  the'precautions,  described  on 
page  68.  Often  the  operating  table  can  be  rolled  alongside 
the  bed  and  the  patient  lifted  ofif,  or  slid  off  by  tipping  the 
table. 

A  nurse,  if  not  a  physician,  should  remain  with  the  patient 
at  least  until  he  is  well  "  out "  of  the  narcosis.  Sometimes  the 
surgeon  will  deem  it  necessary  for  the  assistant  himself  to 
watch  the  patient  for  several  hours  after  an  operation.  It  is 
therefore  important  to  consider  here  some  items  that  may 
require  his  attention. 

147 


148  The  Surgical  Assistant, 

The  Room  should  be  well  ventilated,  but  not  cooled  below 
a  temperature  of  68°  to  70°  F.  The  light  is  to  be  subdued, 
but  not  so  much  excluded  that  the  patient's  features  cannot 
easily  be  watched.  Quiet  is  to  be  maintained  and,  as  a 
rule,  the  family  is  to  be  excluded. 

The  Bed  must  be  prepared  in  advance.  The  upper  sheet  is 
removed  so  that,  for  the  first  few  hours,  the  patient  lies  be- 
neath, or  even  between,  blankets.  The  lower  sheet  is  smoothly 
drawn,  and  across  the  middle  of  it  is  evenly  laid  a  piece  of 
rubber  sheeting  or  oilcloth  about  a  yard  wide.  Over  this, 
and  of  the  same  width,  is  tightly  pinned  a  "  draw  sheet," 
consisting  of  unbleached  muslin  or  of  an  ordinary  sheet 
doubled  over.  In  order  that  the  patient's  head  shall  be  low, 
the  pillows  are  removed  entirely,  or  a  single  flat  pillow  is 
allowed.  Over  it  are  spread  towels,  and  a  basin  is  laid  near- 
by— these  to  provide  for  vomiting.  The  bed  is  to  be  made 
warm  by  the  use  of  several  bags  or  bottles  of  hot  water ;  but 
these  should  be  removed  before  the  patient  arrives,  or  at  least 
it  should  be  determined  that  the  bags  are  not  hot  enough  to 
produce  a  burn,  or  that  they  are  very  well  covered  with 
towels  or  flannnel. 

The  Patient  must  be  laid  in  an  unconstrained  position,  i.  e., 
one  that  does  not  threaten  pressure-paralysis  of  an  extremity. 
If  one  of  the  limbs  has  been  operated  upon,  it  is  placed  on 
a  pillow,  to  which  it  may  be  secured  with  pins  or  bandages. 
Pressure  of  the  bedclothes  upon  it  is  avoided  by  placing 
over  it  a  regular  "  cage,"  or  one  devised  from  barrel-hoops 
or  a  box,  or  by  such  other  means  as  will  suggest  themselves. 

The  patient's  temperature  should  be  noted  soon  after  the 
operation,  and  at  two-  to  four-hourly  intervals  thereafter. 
The  pulse  should  be  studied  as  frequently  as  the  patient's 
condition  may  require. 

Pain  and  Restlessness  usually  come  with  returning  con- 
sciousness, and  frequently  call  for  the  hypodermatic  injection 
of  morphin,  with  or  without  atropin. 

Tightness  of  the  Dressing  is  often  an  early  complaint  of 
the  patient.  If  inspection  prove  it  to  be  indeed  constrictive, 
the  pressure  must,  of  course,  be  relieved — by  nicking  the 


Post-Operative  Vomiting;  Feeding.  140 

bandage  or  by  reapplying  it.  When  plaster  of  Paris  has  been 
employed,  the  extremity  is  to  be  watched  for  evidences  of 
compression.  Swelling  or  cyanosis  of  the  parts  beyond  the 
cast  is  an  indication  that  it  is  too  tight.  Slight  congestion  of 
the  digits  is  not  necessarily  an  indication  of  undue  interfer- 
ence with  the  circulation,  however.  If  the  anemic  spot  under 
the  nail,  produced  by  pinching  with  the  fingers,  is  quickly 
restored  to  its  original  color  when  the  fingers  are  withdrawn, 
the  circulation  in  the  part  is  not  much  interfered  with.  When 
the  edge  of  a  cast  is  found  to  be  pressing  into  the  flesh,  it 
must  be  cut  away  or  lifted  up  with  a  little  cotton  wool. 

Vomiting  is  the  usual  sequel  of  narcosis  by  ether  or  chlo- 
roform, but  it  is  not  constant  in  its  duration  or  severity.  Oc- 
curring before  the  patient  is  "  out,''  the  head  is  to  be  turned 
well  to  one  side,  and  the  jaw  extended;  and,  afterwards,  the 
buccal  cavity  is  to  be  wiped  out.  Occurring  after  the  re- 
flexes have  returned,  the  patient  need  only  be  encouraged  to 
"  spit  out "  whatever  vomitus  remains  in  the  throat.  The 
vomiting  tendency  can  sometimes  be  much  relieved  by  hold- 
ing over  the  nose  an  inhaler  or  handkerchief  wet  with  vin- 
egar. When  the  emesis  is  unduly  persistent,  tincture  of 
iodin  given  in  one-drop  doses  in  a  little  water  at  half-hourly 
intervals  may  prove  quite  useful.  Morphin,  too,  often  re- 
lieves, but  also  often  aggravates,  vomiting. 

Feeding.  After  the  administration  of  ether  or  chloroform, 
no  nourishment  should  be  given  by  mouth  for  a  period  of  six 
hours  (more  or  less,  depending  upon  the  condition  of  the 
patient  and  the  nature  of  the  operation),  and  then  only  if 
the  vomiting  has  ceased  and  nausea  has  largely  disappeared. 
Frequently  a  little  water  may  be  allowed  after  four  hours; 
and  with  children  feeding  can  usually  be  resumed  sooner  than 
with  adults. 

During  the  interval  of  abstinence,  dryness  of  the  mouth 
may  be  relieved  by  wetting  the  lips  with  water ;  and  pellets  of 
ice  may  be  administered  from  time  to  time  after  the  first  hour 
or  two  if  the  vomiting  has  stopped  or  much  diminished.  For 
dryness,  also,  chewing-gum  is  frequently  allowable  to  stimu- 
late salivary  secretion.     Hot  tea  for  adults,  and  milk  and 


150  The  Surgical  Assistant, 

lime-water  for  children,  given  by  the  teaspoonfiil,  are,  as  a 
general  rule,  the  best  articles  with  which  to  inaugurate  feed- 
ing. 

Singultus  occasionally  occurs  during  the  first  hours  after 
an  operation.  In  mild  cases  it  usually  responds  to  such 
measures  as  "  holding  the  breath,"  or  the  application  of  a 
mustard  paste  to  the  epigastrium,  or  the  administration  of 
hot  water  or  of  carminatives  (aromatic  spirits  of  ammonia, 
compound  spirits  of  ether,  compound  tincture  of  cardamom, 
etc.)  When  more  severe  it  frequently  yields  to  morphin, 
while  in  still  more  persistent  cases  belladonna  (the  tincture 
by  mouth,  or  atropin  hypodermatically)  usually  proves  the 
most  effectual  single  remedy.  Rhythmic  tongue  traction  is 
also  of  help.  Faradaization  of  the  phrenic  nerve  and  other 
measures  recommended  for  long-continued  hiccough  scarcely 
need  consideration  in  the  treatment  of  immediately  post- 
operative singultus. 

Urination.  The  patient  should  be  instructed  to  empty  his 
bladder  just  before  the  operation.  For  a  longer  or  shorter 
period  after  an  operation,  especially  one  involving  the  perineal 
region  (the  anus  and  urethra,  in  particular),  the  patient  often 
finds  himself  unable  to  urinate.  Ordinarily,  a  period  of  nine 
hours  may  be  allowed  to  elapse.  If  during  that  time  micturi- 
tion has  not  taken  place,  it  can  frequently  be  brought  about 
by  the  injection  of  a  half  pint  of  warm  water  into  the  rectum, 
the  application  of  a  hot-water  bag  to  the  hypogastrium  or 
[and]  the  administration  of  sweet  spirits  of  nitre  in  tea- 
spoonful  doses  at  half  hourly  intervals.  In  those  instances 
where  there  is  no  objection  to  the  patient  sitting  up  in  bed, 
the  assumption  of  this  posture  may  be  found  all  that  is  neces- 
sary to  accomplish  evacuation  of  the  bladder.  The  sound  of 
running  water  acts  as  an  active  stimulant  to  urination ;  and  it 
must  be  remembered,  too,  that  the  presence  of  another  person 
in  the  room  is  often  a  decided  inhibitory  factor,  especially 
with  nervous  and  sensitive  patients. 

If  these  various  methods  fail  to  accomplish  urination, 
catheterization  must  be  performed  (pages  244  and  255). 
After  plastic  operations  upon  the  vagina  or  perineum,  the 


Shock  vs.   Concealed  Hemorrhage. 


151 


bladder  is  to  be  emptied  with  the  catheter  at  regular  intervals 
of  six  hours  or,  at  least,  to  prevent  infection  of  the  wound, 
it  is  to  be  washed  off  with  some  antiseptic  solution  after  each 
urination   (and  defecation). 

Shock  and  Hemorrhage.  These  two  conditions  have  cer- 
tain symptoms  in  common,  and  while  an  external  hemorrhage 
is  readily  discovered,  the  tragic  error  of  mistaking  for  mere 
shock  a  concealed  hemorrhage  can  easily  be  made  by  the  un- 
wary. Progressiveness  of  the  symptoms,  while  it  may  be 
present  in  shock,  should  in  itself  arouse  strong  suspicions  of 
the  existence  of  a  continued  hemorrhage.  But  the  other 
means  of  differentiation  are  not  few  if  the  evidences  are 
carefully  studied.  The  better  to  contrast  these  evidences, 
they  are  presented  in  parallel  columns : — 


Symptoms  in 

general 
Local  symptoms 


Mentality 

Restlessness 

Pallor 


Sweating 
Respiration 

Pulse 

Effect  of  intravenous 
infusion 

Effect  of  other  stimu- 
lants 

Temperature 


Shock. 
Often  regressive 


Dull;  stuporous 

Slight 

Moderate 

Frequently  present 
Rapid 

Rapid  and  weak 

More  or  less  lasting 


Variable;   may  be  sub- 
normal 
Increased* 


Concealed  Hemorrhage. 
Always  progressive! 

Often  present,  e.g.,  cough  ; 
localized  pain  or  ten- 
derness; abdominal  dis- 
tention; vomiting;  hema- 
temesis;  hematuria;  etc. 

Active 

Often  great 

Very  marked— especially  of 
mucous  membranes;  pro- 
gressive 

Usually  absent 

Marked  and  increasing 
"  air-hunger  " 

More  and  more  rapid  and 
weak 

Transitory 


Often    markedly 

inal 
Decreased] 


[Specific     gravity      of 
the  blood 

Treatment  of  Shock.  The  pillow  is  removed  from  beneath 
the  patient's  head,  and  the  foot  of  the  bed  is  elevated  by 
means  of  bricks,  boxes,  etc.,  or  upon  a  chair  in  the  manner 
illustrated  in  figure  56.  The  patient  is  wrapped  in  blankets 
warmed  in  an  oven,  and  surrounded  with  hot  water  bottles. 
Friction  may  be  applied  to  the  extremities.     To  raise  the 


"V^le — Medical  Record,  August  27,  1904. 


152 


The  Surgical  Assistant. 


general  blood-pressure,  the  limbs  may  be  bandaged  tightly, 
beginning  at  the  digits;  and  this  compression  may  also  be 
applied  to  the  abdomen,  taking  care,  however,  not  to  em- 
barrass respiration. 


Fig.  56.  Elevating  the  foot  of  a  bed  with  a  chair.  Note  flat  pillow,  towel, 
draw-sheet. 

The  judicious  employment  of  stimulants  cannot  be  taught 
in  a  text-book  but  must  be  learned  at  the  bedside.  The  in- 
experienced assistant  is  apt  to  use  them  too  freely,  which, 
however,  is  a  less  serious  fault  than  using  them  too  little. 

Strychnin  (gr.  1-30  injected  hypodermatically,  and  re- 
peated in  an  hour,  if  need  be),  may  be  all  that  is  necessary. 
Other  remedies  may  be  required,  however,  and  of  these  the 
most  serviceable  are  whiskey  (TT^xxx  hypodermatically,  and 
repeated  at  intervals  of  fifteen  minutes  to  three  hours),  digi- 
talis ( nix  of  the  tincture,  TlXiii  of  the  fluid  extract,  or  gr.  1-60 
of  digitalin*),  adrenalin  (TTtx  of  3^0 per  cent,  solution  ad- 
renalin chlorid  every  two  hours),  caffein  (gr.  ii  of  the  sodio- 
salicylate  or  the  sodio-benzoate), ether  (Tllxxx)  and  camphor 
(gr.  i  dissolved  in  olive  oil  or  oil  of  sweet  almonds,  or  in 
ether).  A  "stimulating  enema"  (page  93)  is  a  powerful 
restorative  also,  in  those  cases  especially  where  the  shock  is 

*  There  are  several  preparations  of  digitalin,  and  the  dose  is  not 
the  same  for  all  of  thern, 


Sfxondary  Hemorrhage.  153 

in  large  part  due  to  loss  of  blood  at  the  operation.  In  cases 
of  severe  shock  not  yielding  to  the  above  agencies,  an  intra- 
venous infusion  (page  301)  may  prove  a  life-saving  measure. 

Treatment  of  Hemorrhage.  Here  stimulants  serve  to 
augment  the  bleeding,  and  their  use  should  therefore  be 
reserved  until  after  it  is  checked.  This  is  stated  only  as  a 
general  rule,  however,  for  in  the  presence  of  severe  hem- 
orrhage stimulation  may  be  quite  necessary  to  maintain  heart 
action  during  the  time  that  must  elapse  before  the  bleeding 
vessel  can  be  secured.  Intravenous  saline  infusion  (page 
301),  strychnin,  digitalis  and  adrenalin  are  the  most  useful 
stimulating  remedies.  A  small  dose  of  morphin  may  be  in- 
dicated primarily  as  a  sedative  and  incidentally  as  a  stimu- 
lant. Ergot  (ergotole  or  aseptic  ergot,  hypodermatically)  is 
only  an  adjuvant  in  the  treatment  of  hemorrhage,  and  is  of 
no  avail  when  the  bleeding  is  from  a  large  vessel. 

External  hemorrhage  is  often  controllable  by  means  of 
compression,  as  by  a  tight  bandage,  adhesive  straps  or  sand- 
bags. To  check  bleeding  from  a  wound  in  one  of  the  extrem- 
ities, the  assistant  should  apply  a  tourniquet  (page  289)  ; 
while  in  other  instances  manual  compression  of  large  blood- 
vessels, e.  g.  the  abdominal  aorta,  may  serve  to  hold  the 
hemorrhage  in  check  until  the  surgeon  himself  arrives. 

When  such  means  as  above  described  are  not  available,  and 
the  surgeon  in  charge  is  not  within  immediate  call,  the  assis- 
tant himself  must  promptly  attack  the  bleeding  vessel  or  sur- 
face, wheresoever  it  may  be  : 

Bleeding  from  Wounds  in  General.  Retract  widely  and 
sponge  free  of  blood-clots.  Tie  individual  bleeding  vessels, 
if  accessible.  Treat  general  oozing  by  tight  packing  with 
gauze  (dry,  iodoformized,  is  considerably  more  hemostatic 
than  plain  gauze),  and  a  compressive  bandage. 

From  the  Anterior  Naris.  Plug  with  gauze  strips  or  with 
cotton,  and  apply  ice  compresses  to  the  nose.  The  application 
to  the  mucous  membrane  of  adrenalin  solution  (1-2,000  to 
1-5,000  suprarenal  extract)  or  powdered  antipyrin  is  of  great 
assistance.  Cocain,  too,  is  astringent  as  well  as  anesthetic. 
It  must  be  borne  in  mind,  however,  that  the  reaction  after  the 


154  The  Surgical  Assistant. 

effect  of  these  drugs  passes  ofif  may  be  very  severe,  and  the 
tamponade  must  therefore  be  none  the  less  careful  when  they 
are  used. 

From  the  Posterior  Naris.  Pass  a  catheter  or  probang 
through  the  nostril  to  the  pharynx  and  draw  its  tip  out 
through  the  mouth.  To  this  tip  fasten  with  a  clove-hitch  one 
end  of  a  string  six  or  eight  inches  long,  to  the  other  end  of 
which  is  secured  a  plug  of  gauze.  By  pulling  upon  the 
catheter  the  string  is  drawn  forward  through  the  nose,  and 
the  plug  is  brought  up  to  the  posterior  naris. 

From  the  Tonsil.  Treat  by  the  following  measures,  in 
order,  and  according  to  the  severity  and  persistence  of  the 
bleeding:  upright  position  with  avoidance  of  hawking  and 
coughing ;  ice  in  the  throat  and  ice  bag  externally ;  application 
of  adrenalin  by  swab  or  spray ;  pressure  upon  the  tonsil  with 
a  gauze  pad  which  may  be  coated  with  suprarenal  extract  or 
other  hemotastic ;  digital  compression  of  the  tonsil  and  of  the 
common  carotid  artery,  or,  better,  compression  of  the  gland, 
internally  and  externally,  with  a  special  tonsil  clamp ;  clamp- 
ing and  ligation  of  accessible  spurting  vessels ;  transfixion- 
or  purse-string-suture  of  the  tonsil ;  ligation  of  the  common 
carotid  artery. 

From  Intercostal  Vessels.  Expose  the  wound  and  press 
between,  and  well  beyond,  the  ribs  the  centre  of  a  "  handker- 
chief "  of  gauze.  Into  the  bottom  of  this  pocket  pack  a  strip 
of  gauze.  Then  pull  on  the  "  handkerchief  "  in  oi-der  to 
wedge  the  vessels  tightly  between  the  rib  and  the  wad  of 
gauze.  If  this  fail,  pass  a  hemostatic  suture,  by  means  of  a 
half-curved  needle,  close  to  the  edge  of  the  rib  above  and 
around  the  intercostal  tissues. 

Intra-abdominal  Hemorrhage.  Prepare  hastily,  i.e.^  with- 
out unduly  sacrificing  the  important  element  of  time  to 
the  now  secondary  consideration,  asepsis — towels,  sponges, 
gauze  pads,  ligatures  and  sutures,  a  large  pitcherful  of  hot 
•9  per  cent,  saline  solution,  mouse-tooth  forceps,  scissors, 
[scalpel],  sharp  and  blunt  retractors,  needles  and  needle- 
holder,  ligature-carrier,  clamps,  artery  forceps  and  sponge- 
carriers.     Place  the  patient  upon  a  stretcher  or  table,  and 


Secondary  Hemorrhage.  15.5 

open,  or  re-open,  the  abdomen.  Sponge  out  obstructing 
blood  clots  and  seek  the  bleeding  vessel  or  vessels,  the  prob- 
able location  of  which  is  indicated  by  the  nature  of  the 
primary  operation.  Clamp  firmly  and  apply  ligatures  or 
hemostatic  sutures.  Pour  the  saline  solution,  at  a  tempera- 
ture of  about  105°  Fahr.,  into  the  abdominal  cavity  to  wash 
out  the  remaining  blood,  and  leave  about  a  quart  of  the 
solution  within  the  peritoneal  sac.  Close  the  wound  by 
"  through  and  through  "  sutures  of  silk  or  silkworm-gut. 

If  the  hemorrhage  be  from  a  vessel  in  the  gall  ducts,  the 
assistant  will  do  best  to  simply  apply  a  strong  but  narrow 
clamp,  and  insert  gauze  packings  about  it,  leaving  both  the 
instrument  and  all  the  gauze  strips  protruding  from  the 
wound.  Bleeding  from  the  liver  itself  is  difficult  to  control. 
Clamps  and  sutures  often  tear  through,  and  the  actual  cau- 
tery may  also  avail  nothing.  In  such  instances  apply  gauze 
packings  and  a  firm,  compressive  dressing.  Cholemia,  often 
present  in  conditions  requiring  operation  upon  the  biliary 
tract,  is  a  pronounced  hemorrhagic  factor,  and  so  packing 
and  even  ligating  may  not  in  themselves  suffice  to  control 
the  bleeding.  When  it  is  thus  persistent,  strong  and  con- 
tinuous manual  pressure  directly  over  the  dressing  must  be 
maintained  for  many  hours. 

From  the  Kidney  (after  nephrotomy).  Retract  the 
wound  and  have  the  nurse  or  other  helper  push  the  organ 
into  it  by  pressure  from  in  front  (figure  84).  Sponge  out 
the  wound  in  the  kidney  and  pack  it  with  gauze ;  pack  also 
around  the  kidney.  If  this  fail  to  check  the  bleeding,  which 
is  unlikely,  pass  heavy  catgut  sutures  through  the  substance 
of  the  organ. 

From  the  Renal  Pedicle  (after  nephrectomy).  Search 
with  a  finger  in  the  opened  wound  for  the  renal  artery,  and 
seize  the  vessels  in  a  clamp  directed  along  the  finger.  Leave 
the  instrument  in  the  wound  and  pack  gauze  around  it.  If 
the  pedicle  cannot  be  reached,  open  the  abdomen  promptly 
and  ligate  or  compress  the  renal  vessels  transperitoneally. 

From  the  Bladder.  Place  the  patient  in  the  Trendelen- 
burg position  in  such  a  manner  as  to  direct  a  good  light  into 


156  The  Surgical  Assistant. 

the  bladder.  If  necessary,  insert  gauze  above  the  fundus  to 
protect  the  peritoneal  cavity  against  soiling.  Open  or  re- 
open the  bladder  and  retract  the  wound  with  guy  threads  or 
forceps.  Sponge  out  blood  clots  and  pack  the  viscus  syste- 
matically and  tightly  with  gauze  strips.  Individual  vessels 
may  be  secured  by  hemostatic  sutures,  while  light  touches  of 
the  actual  cautery  are  of  aid  in  stopping  the  hemorrhage 
from  a  larger  or  smaller  surface. 

Gauze  packing  may  fail  to  stop  the  bleeding  from  large 
vessels  at  the  base  of  the  bladder.  In  such  a  case  employ 
the  following  device :  Transfix  several  small  superimposed 
squares  of  gauze  with  a  double  strand  of  heavy  silk,  or  of 
twine,  about  six  inches  long.  Carry  the  silk  directly  through 
the  perineum,  either  by  means  of  a  heavy  needle  or  with  for- 
ceps, and  pull  upon  it  so  as  to  bring  the  gauze  tightly  against 
the  bleeding  surface.  Fasten  the  silk  to  the  external  dress- 
ing or  to  the  thigh. 

From  the  Perineum  (after  prostratectomy,  urethrotomy, 
cystotomy,  etc.).  Retract  the  wound,  tie  individual  vessels, 
secure  the  drainage  tube  in  position,  pack  gauze  strips  about 
it  and  apply  a  compressive  dressing. 

From  the  Rectum.  If  the  hemorrhage  is  moderate,  insert 
a  large  "  tampon-canula  "  (page  279).  If  the  loss  of  blood 
be  large  or  continue  in  spite  of  the  tampon,  introduce  a 
speculum,  clamp  and  tie  bleeding  vessels  and  then  insert  the 
tampon-canula.  In  some  instances,  as  in  bleeding  after  the 
division  of  a  stricture,  a  "  canule  a  chemise"  will  prove  more 
efifective  than  the  tampon-canula.  The  use  of  a  tube,  instead 
of  packing  the  rectum  with  gauze  alone,  has  the  advantages 
of  making  continued  hemorrhage  manifest  by  the  escape  of 
blood  into  the  dressing,  and  of  permitting  the  passage  of 
flatus. 

From  the  Uterus  (post-partum).  Administer  by  means  of 
a  Chamberlain  tube  or  other  uterine  irrigation  tip,  a  copious 
hot  (115°  Fahr.)  douche  of  .9  per  cent,  sahne,  or  1-10,000 
sublimate  solution,  or  of  plain  water  to  which  may  with 
advantage  be  added  half  an  ounce  of  acetic  acid  to  each 
quart.     Stimulate  contraction  of  the  uterus  by  pressure  on, 


Pulmonary  Edema.  157 

and  manipulation  of,  the  fundus,  and  by  the  administration 
of  ergot.  If  these  measures  fail,  pack  the  organ  systemati- 
cally with  long  strips  of  gauze.  Continue  pressure  upon  the 
fundus  for  one  hour. 

From  the  Cervix  Uteri.  If  hot  douches  and  gauze  pack- 
ings are  insufficient,  pass  a  hemostatic  suture. 

The  after  treatment  of  severe  hemorrhage  is  that  of  shock 
due  to  any  cause,  described  above.  The  use  of  saline  infu- 
sions is  especially  indicated. 

Pulmonary  Edema  manifests  itself  by  increasing  dyspnea 
and  cyanosis,  by  moist  rales  that  become  louder  and  louder 
and  more  diffused  over  the  chest,  and  by  the  appearance, 
a  little  later,  of  a  profuse  cold  sweat.  The  treatment  must 
be  prompt,  vigorous  and  persistent.  Nitroglycerin  and  atro- 
pin,  administered  hypodermatically  in  large  doses  (gr.  1-50 
of  each)  and  repeated  to  the  physiological  limit,  are  the  most 
important  remedies.  Stimulants,  notably  strychnia,  are  also 
indicated  to  assist  the  heart  in  overcoming  the  pulmonary 
stasis.  A  small  dose  of  morphin  (gr.  J  )  may  be  of  much 
service.  Oxygen  is  often  of  real  use  and,  at  any  rate,  should 
be  sent  for  early  lest  the  assistant  otherwise  subject  himself 
to  the  unfriendly  criticism  of  the  patient's  family.  The  gas 
should  be  allowed  to  escape  from  the  tank  only  in  sufficient 
volume  to  bubble  at  a  moderately  rapid  rate  through  the 
bottle  of  water.  The  tip  of  the  tube  attached  to  the  bottle  is 
held  in  the  patient's  nostril. 

All  the  mechanical  methods  of  abstracting  and  diverting 
blood  from  the  lungs  must  be  brought  into  play.  The  head 
of  the  bed  is  to  be  raised.  Cups  should  be  applied  freely  to 
the  chest  both  anteriorly  and  posteriorly.  Lacking  the 
regular  cupping  glasses,  medicine-  and  wine-tumblers  make 
very  acceptable  substitutes.  The  method  of  using  them  that 
minimizes  the  dangers  of  burning  the  patient  and  of  igniting 
the  bedclothes,  is  the  following:'  A  torch  is  made  by  winding 
a  little  cotton  about  the  end  of  an  opened  hairpin  or  of  a 
probe.  This  is  dipped  in  alcohol  and  lighted,  then  rubbed 
rapidly  about  the  interior  of  the  cup,  which  is  to  be  promptly 
clapped  on  the  chest.    "  Bleeding  the  patient  into  himself  "  is 


158  The  Surgical  Assistant, 

accomplished  by  applying  constrictors  to  the  limbs  near  their 
roots,  one  or  two  extremities  at  a  time,  and  for  periods  of  not 
over  half  an  hour  each,  the  constriction  being  only  tight 
enough  to  compress  the  veins  without  obstructing  the  arterial 
supply.  When  the  tourniquet  is  properly  applied,  the  super- 
ficial veins  dilate  visibly,  and  the  extremity  becomes  cyanosed 
and  swollen.  Hot  applications  are  to  be  made  to  the  limbs 
not  at  the  time  being  constricted. 

Actual  blood-letting  (phlebotomy)  is  indicated  only  in 
plethoric  individuals.  The  arm  is  prepared  and  bandaged, 
as  described  for  intravenous  infusion,  and  the  vein  is  ex- 
posed in  the  same  manner.  There  are  these  differences, 
however,  that  the  distal  ligature  is  not  tied  in  advance  (the 
proximal  ligature  may  be)  and  that  the  bandage  is  not  cut 
through  until  after  the  operation  is  completed.  The  vein  is 
opened  with  a  scalpel  or  with  scissors.  A  towel  or  basin 
held  above  the  wound  wdien  the  vein  is  opened  prevents 
soiling  of  the  bedclothes.  If  the  exposed  vein  segment  is 
compressed  digitally  above  and  below  until  after  it  is  opened, 
and  a  canula  is  inserted  (towards  the  patient's  fingers),  spat- 
tering is  avoided  and  the  blood  may  be  directed  neatly  into 
a  glass  graduate.  Six  to  twelve,  or  even  sixteen  ounces, 
may  be  withdrawn.  When  sufficient  blood  has  been  sacri- 
ficed, the  vein  is  again  compressed  with  a  finger,  the  ligatures 
are  tied  and  the  vessel  is  divided  between  them,  the  bandage 
is  cut  through,  and  the  wound  is  rapidly  dressed  with  a  bit 
of  gauze. 

Uremic  (Eclamptic)  Convulsions.  A  wedge  or  gag  is  to 
be  slipped  between  the  teeth  to  prevent  injury  to  the  tongue. 
A  handkerchief  or  mask  well  wet  with  chloroform  is  held 
over  the  face  so  that  the  patient  inhales  the  vapor  as  soon  as 
the  respiratory  spasm  subsides.  With  the  chloroform  the 
convulsions  are  controlled,  either  by  keeping  the  patient  in 
a  state  of  mild  narcosis,  or  by  applying  the  mask  the  instant 
a  recurrence  of  twitching  appears.  The  rest  of  the  imme- 
diate treatment  consists  in  reducing  the  arterial  tension  and 
in  securing  activity  of  the  emunctories.  Hot  packs,  consist- 
ing in  wrapping  the  patient  in  blankets  wrung  out  in  very 


Poisoning  by  Antiseptics.  159 

hot  water,  are  to  be  used  freely.  Vasculo-dilators,  e.  g., 
nitroglycerin,  are  also  to  be  employed.  If  a  reliable  prepara- 
tion of  veratrum  viride  is  obtainable,  a  hypodermatic  injec- 
tion of  TTtiii  of  the  fluid  extract  or  r(\y  of  the  tincture  may  be 
administered,  and  this  the  assistant  may  repeat  in  two  or 
three  hours  if  the  first  dose  has  not  effected  softening,  en- 
feeblement,  or  irregularity  of  the  pulse,  or  reduction  of  its 
rate  below  ninety.  Phlebotomy  (vide  supra),  followed  by 
intravenous  or  rectal  saline  infusion,  is  indicated  if  the 
patient  is  not  anemic  or  has  not  already  lost  much  blood. 

Poisoning  by  the  Absorption  of  Antiseptics  seldom  gives 
symptoms  within  the  first  few  hours  after  operation,  and  will, 
therefore,  be  but  briefly  considered. 

Carbolic  acid  absorption  produces  pallor,  labored  respira- 
tion, drowsiness  deepening  into  coma,  and  collapse ;  pupils 
normal  or  contracted ;  urine  olive-green.  Treat  by  changing 
the  dressing  and  irrigating  the  wound  and  by  administer- 
ing stimulants  and  diuretic  agencies. 

Poisoning  by  bichloride  of  mercury  produces  salivation, 
diarrhea,  vomiting,  rapid  and  feeble  pulse,  sometimes  sup- 
pression of  urine.  Change  the  dressing,  wash  the  wound, 
administer  water  and  purgatives. 

Iodoform  poisoning.  In  mild  cases  there  are  produced  a 
vivid  rash  about  the  wound,  mental  excitation  and  the  iodin 
reaction  in  the  urine.  In  severe  cases  the  cerebral  symptoms 
are  marked — delirium  or  mania,  but  sometimes  coma — and 
the  scarlatiniform  rash  spreads  over  other  parts  of  the  body; 
pyrexia  develops,  the  pupils  become  contracted  and  the  pulse 
is  rapid  and  feeble;  collapse  may  supervene.  Remove  all 
iodoform  from  the  wound,  and  employ  symptomatic  treat- 
ment. Carbonate  of  potash  is  said  to  be  an  antidote  to  iodo- 
form, and  may  be  used  both  locally  and  internally. 


PART    II. 


PART   II. 

CHAPTER  XI. 

OPERATIONS  UPON  THE  HEAD. 
THE   CRANIUM. 

Trephining. 

The  anesthetist,  as  for  all  aseptic  operations  upon  the 
head  and  neck,  should  wear  a  sterilized  gown  and  a  cap,  and 
should  disinfect  his  hands.  All  of  his  tools  should  be  steril- 
ized or  covered  with  aseptic  gauze.  In  addition,  it  is  wise  for 
him  to  so  place  a  sterilized  towel  that  it  will  safeguard 
against  contact  between  the  operators'  hands  and  his  own. 
The  narcotizer  should  stand  or  sit  at  the  side  of  the  table 
opposite  to  the  operator.  He  will  usually  be  least  in  the  way 
if  he  seats  himself  opposite  the  patient's  chest.  It  is  worth 
repeating  here  that  he  should  guard  the  patient's  eyes  from 
any  inadvertent  pressure. 

The  instrument  hander  arranges  his  tools  in  about  the  fol- 
lowing order :  scalpels,  mouse-tooth  forceps,  anatomical  for- 
ceps, hemostats,  scissors,  retractors,  periosteal  elevator,  raspa- 
tory, trephines  (the  adjustment  of  the  central  pins  of  which 
is  to  be  inspected),  bone-seizing  forceps,  De  Vilbiss  or  other 
bone-cutting  forceps,  [Gigli  wire  saw],  rongeurs,  sharp 
spoons,  chisels,  gouges,  mallet,  probes,  [bullet  searcher] ,  [as- 
pirating syringe],  needle  holder.  In  the  dishes  he  arranges 
a  number  of  fine  and  medium-sized  catgut  ligatures,  and 
sutures  appropriate  for  the  meninges  (fine  catgut)  and  for 
the  scalp  (silk  or  catgut).  From  a  dish  of  sterilized  Hors- 
ley's  wax  a  few  plugs  are  removed  with  a  spoon  and  placed 
within  ready  reach  ;  and  in  addition  the  assistant  places  on  his 

163 


164  The  Surgical  Assistant. 

table  some  gauze  packings  and  a  piece  of  rubber  tissue  pre- 
pared as  previously  described. 

If  an  electric  or  other  motor  is  to  be  used  for  driving  tre- 
phines or  burrs,  as  much  of  the  apparatus  as  may  come 
within  the  field  of  operation  should  be  covered  with  gauze 
(wound  about  it).  Similarly,  the  instrument  bander  should 
cover  the  rheophores  of  an  electric  battery  that  may  be  used 
on  the  brain  and,  it  need  hardly  be  said,  he  should  sterilize 
the  platinum  electrodes. 

The  patient  is  placed  with  his  head  well  supported  on  a 
towel-covered,  flat  or  wedge-shaped,  pillow  at  one  end  of  the 
operating  table,  so  disposed  as  to  secure  the  best  light  in  the' 
wound.  Below  should  be  a  slop-pail.  If  the  scalp  has  not 
been  already  prepared,  it  should  now  be  shaved,  either  com- 
pletely or,  at  least,  over  a  wide  area.  The  skin  is  then  to  be 
disinfected,  as  described  in  chapter  V.  It  is  well  to  include 
the  face  in  this  toilet  in  order  to  minimize  the  contamination 
of  the  anesthetist's  hands.  A  fresh  towel  is  next  spread  over 
the  pillow,  removing  the  first  one  if  it  is  wet  (as  it  is  apt 
to  be).  If  a  Martin's  constrictor  is  to  be  employed,  it  should 
be  applied  at  this  juncture,  being  passed  circularly  about  the 
head,  just  above  the  auricles  and  the  eyebrows  and  just  below 
the  occipital  protuberance,  and  secured  at  the  point  of  cross- 
ing with  a  piece  of  bandage.  Towels  are  now  spread  freely 
about  the  field  of  operation,  and  the  head  is  turned  so  that 
this  site  is  uppermost. 

After  passing  scalpel  and  mouse-tooth  forceps,  the  instru- 
ment bander  should  be  ready  with  hemostats.  He  should 
select  the  Hartley  T-shaped  or  Spencer  Wells  pedicle  clamps, 
if  they  are  provided,  for  the  scalp  bleeds  all  along  the  cut  sur- 
face and,  besides,  ordinary  hemostats  are  not  here  easily  re- 
tained. Although  the  T-clamps,  gripping  as  they  do  the 
entire  thickness  of  the  scalp,  may  be  used  as  retractors,  it  is 
perhaps  better  for  the  assistant  to  insert  the  usual  instru- 
ments for  drawing  aside  the  skin-flap.  What  will  next  be  re- 
cjuired  of  him  will  depend  upon  the  nature  of  the  operation. 
If  it  is  for  depressed  fracture  there  should  next  be  passed  a 
probe  and  a  periosteal  elevator.    After  these  no  other  instru- 


Trephining.  165 

ments  may  be  needed  than  bone  forceps  [and  scissors]  for 
removing  fragments,  rongeurs  for  smoothing  off  projecting 
bone  edges,  sutures  for  the  external  wound,  and  a  "  cigar- 
ette "  or  other  drain.  Utmost  gentleness  and  caution  must  be 
exercised  when  sponging  over  a  fractured  cranial  bone.  If 
the  trephine  is  used,  the  assistant  should  support  the  head 
and,  as  opportunity  offers,  sponge  away  the  bone  dust.  As 
the  operator  removes  the  trephine  from  time  to  time,  there 
should  be  placed  in  his  hand  a  fine  probe,  with  which  he  may 
test  the  depth  of  his  cut.  If  the  button  of  bone  does  not 
happen  to  come  away  with  the  final  removal  of  the  trephine, 
an  elevator  is  given  to  the  surgeon  to  pry  it  out,  after  which  a 
probe  is  again  handed  to  explore  the  epidural  space. 

When,  in  operating  for  any  cerebral  or  meningeal  lesion, 
or  in  excision  of  the  Gasserian  ganglion,  a  bone-flap  is  to  be 
raised,  the  assistant  should  hand  a  trephine  for  making  two 
or  more  apertures,  and  then  instruments  for  connecting  these 
openings, — De  Viibiss  or  other  bone-cutting  forceps,  Gigli 
wire  saw  and  director  upon  which  to  pass  it.  Van  Arsdale 
saw,  bone  drill,  or  gouge  and  mallet,  according  to  the  oper- 
ator's preference.  After  the  [skin-  and]  bone-flap  has  been 
raised,  it  is  to  be  retracted,  preferably  in  a  piece  of  gauze,  by 
the  assistant,  who  must  exercise  care  not  to  strip  the  bone 
from  its  periosteal  covering.  Bleeding  from  a  vessel  in  the. 
bone  calls  for  the  use  of  a  tiny  plug  of  wood  or  of  wax,  which 
the  instrument  bander  passes  in  the  palm  of  his  hand  or  in  a 
saucer,  or  for  the  introduction  into  the  bony  channel  of  a 
heated  wire  (e.  g.,  one  from  an  aspirating  needle).  The  lift- 
ing of  a  bone-flap  may  cause  severe  hemorrhage  from  a  men- 
ingeal vessel  torn  at  a  point  inaccessible  to  forceps  or  suture. 
At  its  appearance  the  assistant  should,  therefore,  be  ready 
with  a  gauze  packing. 

Before  dividing  the  meninges  the  operator  may  desire  to 
secure  some  of  their  bloodvessels,  and  for  this  purpose  he 
should  be  given  a  fine  catgut  suture  on  a  small  round  needle. 
For  the  incision  into  the  dura  there  are  to  be  handed  two 
small  mouse-tooth  forceps,  and  a  pair  of  small  blunt-pointed 
straight  scissors  or  a  delicate  scalpel.     To  secure  bleeding 


166  The  Surgical  Assistant. 

points  in  the  brain  itself,  serrefines  (appendix,  figure  43) 
should  be  passed,  if  they  are  provided,  for,  being  light,  they 
are  less  apt  to  tear  out  than  ordinary  hemostats.  If  the  latter 
are  used  therefore,  they  should  be  supported  in  position  by 
the  assistant's  hand  until  the  ligatures  are  applied. 

When  the  wound  is  to  be  closed  the  assistant  gently 
sponges  off  the  bone-flap  and  removes  the  T-clamps  from 
the  scalp.  Vessels  that  then  bleed,  unless  of  large  size,  will 
be  secured  by  the  scalp  sutures.  These  are  usually  inter- 
rupted and  of  catgut,  and  should  be  threaded  on  stout 
needles.    A  gauze  drain  may  be  desired. 

The  dressijig  should  be  retained  by  an  evenly  compressing 
recurrent  bandage,  and  this,  in  turn,  may  well  be  secured 
with  a  starch-crinolin  roller. 

The  assistant  should  support  the  head  while  the  patient  is 
being  lifted  from  the  table  and  into  his  bed. 

MASTOID   OPERATIONS. 

The  assistant  places  the  patient's  head  on  a  firm,  flat, 
wedge-shaped  or  cylindrical  pillow,  the  diseased  area  upper- 
most. The  hair  is  to  be  shaved  from  the  region  about  the 
mastoid  process,  the  rest  of  the  scalp  being  covered  by  a 
towel  (page  84)  or  a  rubber  cap.  The  locks  of  hair  that 
straggle  from  under  the  cap,  if  the  patient  is  a  female,  may 
be  pasted  back  with  collodion.  The  external  auditory  canal 
is  then  irrigated  with  a  boracic  acid  or  other  antiseptic  solu- 
tion, and  then  the  cheek,  auricle,  mastoid  region  and  neck 
are  to  be  scrubbed  and  disinfected.  After  this  the  towels 
are  spread,  and  a  bit  of  absorbent  cotton  or  a  narrow  strip 
of  gauze  may  be  lightly  packed  into  the  auditory  meatus. 

The  instruments  should  be  arranged  much  as  for  trephin- 
ing, the  coarser  bone  tools  used  in  that  operation  being  re- 
placed here  by  the  smaller  mastoid  burrs,  gouges,  chisels  and 
curettes  (appendix,  figs.  66-68).  These  are  spread  out 
systematically,  according  to  their  sizes  and  shapes.  An  aural 
hand-syringe  and  a  basin  of  irrigating  solution,  a  pus  basin 
(sterilized  or  covered  with  a  sterile  towel),  one  or  two  small 


Mastoid  Operations. 


167 


saucers  and  a  supply  of  bone  wax  should  be  at  hand.  But 
few  ligatures  need  be  prepared.  A  few  sutures  of  silk,  cat- 
gut or  horsehair  should  be  mounted  on  stout,  full  curved 
("  mastoid  ")  needles.     If  the  operation  be  extended  into  the 


Fig.  57.  Position  of  the  head  for  operation  upon  the  lower  jaw  or  neck. 
For  a  mastoid  operation  the  rubber  cap  should  not  be  drawn  quite  so  far  down. 

neck,  e.  g.,  to  explore  the  jugular  vein,  one  or  two  sutures 
are  to  be  threaded  on  ordinary  surgical  needles ;  and  if  a 
complete  Stacke  operation  is  found  necessary,  the  assistant 
prepares  silk  sutures  on  small  round  needles  for  fastening 
the  incised  concha  in  its  new  position. 

A  generous  supply  of  bits  of  sea-sponge  should  be  torn. 
These  should  be  placed  in  a  dish,  together  with  a  pair  of 
thumb  forceps,  or,  better  yet,  several  of  them  are  securely 
mounted  on  artery  forceps  and  their  loose  edges  trimmed  with 
scissors.  The  sizes  of  these  sponges  should  be  altered  to  suit 
the  varying  depth  and  width  of  the  cavity  in  which  the  opera- 


168  The  Surgical  Assistant. 

tor  is  working.  Larger  pieces  may  be  rinsed,  squeesed  dry, 
and  used  repeatedly,  but  very  small  bits  of  sponge  should  be 
discarded  after  using  once. 

Sea-sponge,  unless  quite  compact,  tears  on  rough  bone 
and  it  is  well,  therefore,  for  the  assistant  to  prepare  strips 
of  gauze  about  an  inch  wide  and  six  inches  long  and  free  of 
raveled  edges.  When  needed  for  "  sponging  "  several  of 
these  strips  are  placed  near  the  wound  and  with  them  a 
probe  for  their  manipulation. 

A  longer  piece  of  gauze  of  the  same  width  and  double 
thickness,  is  to  be  laid  aside  on  the  instrument  table  for  plug- 
ging the  lateral  sinus  should  it  be  inadvertently  opened. 

When  the  primary  incision  has  been  made  hemostats  are 
passed  and  after  them  ligatures,  to  be  tied  at  once  since  the 
forceps  are  apt  to  be  dislodged  or  to  obstruct  manipulations 
if  left  in  situ.  The  insertion  of  retractors  will  stop  the  bleed- 
ing from  most  of  the  vessels  running  through  the  soft  parts 
over  the  mastoid  process. 

Care  should  be  taken  not  to  bruise  the  auricle  with  the 
retractor.  When  the  bone  is  reached  the  operator  is  relieved 
of  the  scalpel  and  given  an  elevator  for  the  periosteum  (un- 
less this  tissue  is  destroyed  by  the  disease  process).  In  turn 
this  is  to  be  replaced  by  an  instrument  for  attacking  the  bone 
itself,  which  the  assistant  should  select  according  to  the  pref- 
erences of  the  surgeon  and  the  conditions  present.  Some 
mastoid  operators  depend  chiefly  upon  chisels  and  gouges, 
while  others  prefer  burrs.  If  the  bone  surface  is  normal  or 
sclerosed  a  mallet  is  handed  with  the  gouge ;  if  it  is  eroded 
the  gouge  alone  may  be  required ;  while  if  the  bone  surface 
is  much  destroyed,  especially  if  the  patient  is  a  young  child, 
a  sharp  spoon  will  suffice.  The  instrument  bander  should 
closely  follow  the  development  of  the  operation,  so  that  he 
may  forestall  the  surgeon's  request  for  a  larger  or  a  smaller 
curette  and  will  at  the  proper  time  hand  him,  unasked,  a 
rongeur  to  remove  a  ledge  of  bone,  etc. 

Aside  from  holding  retractors,  the  assistance  at  the  wound 
consists  chiefly  in  sponging  and  in  removing  bone  fragments. 


Mastoid  Operations. 


169 


The  sponging  must  be  assiduous,  but  none  the  less  judicious. 
It  would  be  unwise,  for  example,  to  too  hastily  wipe  away 
a  drop  of  pus  that  may  appear,  for  with  it  may  be  removed 


Fig.  58.    Gauze  to  be  laid  over  the  mastoid  wound,  trimmed  to  fit  against 
the  auricle. 


the  early  clue  to  a  new  site  of  operative  attack.  Again,  if 
an  area  of  brain  tissue  or  of  the  sigmoid  sinus  is  exposed, 
an  infectious  bone  fragment  may  be  thrust  into  it  by  spong- 
ing that  is  more  vigorous  than  cautious. 

The  removal  of  bone  fragments  is  better  accomplished 
with  dressing-  than  with  anatomical-forceps.  Two  warnings 
should  be  given  here,  viz. :  to  avoid  injury  by  the  forceps  to 
the  facial  nerve,  if  the  Fallopian  aqueduct  has  been  opened ; 
and  to  refrain  from  pulling  upon  any  bone  particles  not 
altogether  freed  from  the  periosteum,  without  first  complet- 
ing the  detachment  with  a  snip  of  the  scissors.  The  last  is  a 
small  detail  in  technic,  but  an  important  one, — the  tearing 
away  of  a  still  adherent  bit  of  bone  at  the  mastoid  apex  may 
bring  with  it  a  few  fibres  of  the  sterno-mastoid  muscle,  and 
thus  open  a  channel  of  infection,  in  the  neck, 


170 


The  Surgical  Assistant. 


After  the  bone  cavity  has  been  cleansed  and  packed  the 
retractors  should  be  withdrawn,  and  any  bleeding  vessels 
secured.  The  dressing  is  then  to  be  applied.  In  order  that 
the  auricle  shall  not  be  distorted  the  deeper  layers  of  gauze 
may  be  trimmed  to  fit  the  posterior  surface  of  the  concha. 
A  plug  of  absorbent  cotton  is  then  to  be  placed  lightly  in  the 
auditory  canal,  and  the  auricle  evenly  covered  with  a  smooth 
pad  of  gauze  or  cotton  wool.  If  there  is  little  oozing  of  blood 
and  the  dressing  is  soon  to  be  changed,  the  outer  layers  of 


Fig.  59.    Mastoid  dressing  firmly  retained  and  reduced  in  bulk  by  the  ap- 
plication of  a  starch  bandage. 


gauze  may  be  wet  in  a  solution  of  salt,  aluminum  acetate 
(liquor  Burowii),  bichlorid  of  mercury,  etc.,  and  covered 
with  gutta-percha  tissue,  oiled  silk  or  wax  paper.  Over  this 
is  laid  a  thin  layer  of  cotton  wool.  The  bandage,  two  inches 
wide,  is  applied  in  oblique  turns  over  the  scalp  and  figure-of- 
eight  turns  about  the  forehead  and  neck.  If  a  starch  band- 
age be  applied  over  this  the  neck  turns  may  be  omitted — 
which  will  save  the  patient  much  discomfort. 


CHAPTER  XII. 

OPERATIONS  UPON  THE  HEAD.— Continued. 

OPHTHALMIC   OPERATIONS. 

Extraction  of  Cataract.  This  operation  should  be  per- 
formed in  the  patient's  bed,  and  the  assistant  should  see  that 
the  pillows  are  so  arranged  that  the  head  will  have  to  be 
moved  little,  or  not  at  all,  when  the  operation  is  concluded. 
The  necessity  for  changing  the  shirt  or  pillow-covers  is, 
therefore,  to  be  avoided  by  protecting  these  with  rubber 
sheeting. 

After  irrigating  the  conjunctival  sac  with  warm  boracic 
acid  solution  (saturated)  from  a  sterile  "  undine"  or  small 
pitcher,  and  instilling  cocain  or  other  solutions,  the  eyelids, 
forehead  and  cheek  should  be  gently  cleansed  with  water  and 
castile  soap,  by  means  of  an  absorbent  cotton  mop.  This 
may  be  followed  by  an  application  of  a  weak  sublimate  solu- 
tion, and  a  second  boracic  acid  irrigation  of  the  conjunctiva. 
The  patient's  head  is  now  placed  in  proper  position  on  the 
pillow,  viz.:  well  extended  and  facing  directly  upwards. 
The  sound  eye  is  covered  with  a  pad  of  absorbent  cotton, 
and  sterile  towels  are  laid  over  the  brow  and  scalp  (this 
towel  should  be  pinned  to  the  pillow,  or  otherwise  fastened), 
over  the  face  and  on  the  pillow. 

If  the  eye  is  to  be  illuminated  by  artificial  light  condensed 
by  a  refracting  lens,  the  assistant  to  whom  this  instrument  is 
entrusted  should  assume  a  position  which  he  can  maintam, 
unvaryingly,  throughout  the  operation,  for  if  the  lens  be 
shifted  at  a  critical  moment  a  human  eye  may  be  sacrificed 
in  consequence.  The  entire  cornea,  if  not  the  entire  eyeball, 
is  to  be  steadily  illuminated. 

The  preparation  of  the  instruments  has  already  been  de- 

171 


172 


The  Surgical  Assistant. 


scribed  (pages  103  and  107).  The  operator  should  not  be 
obHged  to  turn  his  eyes  even  for  a  moment  from  the  operat- 
ing field.  It  is  important,  therefore,  that  the  instrument 
passer  should  place  in  his  hand  the  proper  instrument, 
promptly  and  in  the  exact  direction  in  which  the  operator 
is  to  apply  it.  Similarly,  after  an  instrument  has  been  used, 
the   assistant    should   be   ready   to   take   it   promptly   from 


Fig.  60.  Manner  of  passing  instruments  and  "  illuminating  "  for  a  cataract 
extraction. 

the  surgeon's  hand.  The  handles  only  of  the  tools  are  to 
be  touched,  and  the  points  should  come  in  contact  with 
nothing  between  the  sterile  basin  and  the  eye,  the  eye  and 
the  basin  again.  If  an  instrument  that  is  bloody  is  needed 
a  second  time,  however,  it  may  be  dipped  into  boiled  water 
and  dried  with  a  bit  of  sterilized  linen,  several  pieces  of 
which  should  be  at  hand. 

The  following  is  the  order  in  which  the  instruments  are 
passed:  spring  wire  speculum  ("right-sided"  or  "left- 
sided  "  as  the  case  may  be)  ;  fixation  forceps  ;  cataract  knife  ; 


Cataract;  Strabismus. 


173 


iris  forceps ;  iris  scissors,  de  Wecker  or  other  iridectome,  if 
iridectomy  is  required ;  cystotome  for  dividing  the  lens 
capsule ;  spoon  for  expressing  the  cataract ;  iris  repositor. 
(Appendix,  figures  58-63.) 

In  addition  to  illuminating  and  instrument  handing,  such 
other  assistance  as  may  be  needed  will  consist  in  holding  the 
fixation  forceps  for  a  moment,  and  in  sponging.  There  is 
usually  but  little  blood  that  needs  to  be  wiped  away.  The 
sponging  is  to  be  by  pledgets  of  moist  absorbent  cotton,  free 
of  projecting  fibres,  and  it  should  carefully  avoid  pressure 
on  the  eyeball  or  contact  with  the  wound  itself.  If  the  latter 
requires  cleansing  by  sponging  or  irrigation,  this  is  per- 
formed by  the  operator  himself. 


Fig.  61.     Eye  pads  in  a  shallow  basin  of  boracic  acid  solution. 


Iridectomy  requires  the  same  assistant's  technics  as  de- 
scribed above,  the  cystotome  and  spoon,  however,  not  being 
needed.  It  is  not  necessary  to  perform  this  operation  in  the 
patient's  bed. 

Strabismus.  The  assistant  passes  the  instruments  in  the 
following  order  :  speculum,  fixation  forceps  ;  conjunctiva  for- 
ceps and  scissors ;  strabismus  hook ;  tendon  scissors ;  tendon 
sutures  (unless  simple  tenotomy  is  performed)  ;  conjunc- 
tival sutures.  The  sutures,  not  longer  than  eight  inches,  are 
usually  of  iron-dyed  silk  and  mounted  on  small  curved 
needles.     It  is  best  for  the  assistant  to  have  half  ^  dozen 


174 


The  Surgical  Assistant, 


sutures  prepared  in  advance,  for  in  some  strabismus  opera- 
tions they  are  inserted  into  tlie  tendons  before  the  latter  are 
divided. 

Enucleation  requires  the  following  instruments,  in  order: 
speculum;  fixation  forceps;  conjunctiva  scissors;  strabismus 
hook ;  tendon  scissors,  and  either  the  same  or  a  stronger  pair 
of  scissors  to  divide  the  optic  nerve ;  gauze  pad  for  pressure 
until  the  hemorrhage  ceases;  conjunctival  suture. 


Fig.  62.    Dressing  and  bandage  of  one  eye. 


The  eye  dressings  to  be  handed  to  the  operator,  or  applied 
by  the  assistant,  are  ordinarily,  first,  one  or  more  flat  circular 
pads  of  absorbent  cotton  about  two  and  a  half  inches  in  diam- 
eter (several  of  which  pads  should  be  prepared  in  advance, 
either  dry  or,  preferably,  kept  in  a  shallow  dish  of  boracic 
acid  solution — fig.  6i),  over  this,  loose  pads  of  dry  cotton 
to  fill  in  evenly  the  orbito-nasal  hollow,  and  then  a  two-inch 


Removal  of  the  Upper  Jaw.  I'/'S 

roller.  Beginning  at  the  centre  of  the  forehead,  the  bandage 
is  applied,  smoothly  and  without  exerting  pressure,  in  cir- 
cular and  oblique  ("  figure  of  eight  ")  turns.  If  the  patient 
wears  a  braid,  the  circular  turns  pass  above  it,  the  oblique 
turns  below  it,  thus  adding  to  the  security  of  the  dressing 
and  to  the  comfort  of  the  patient.  After  a  cataract  operation 
both  eyes  should  be  bandaged  ("double  figure  of  eight"). 

REMOVAL   OF   THE   UPPER    JAW. 

The  following  are  needed :  scalpels,  mouse-tooth  and 
anatomical  forceps,  dressing  forceps,  straight  and  curved 
scissors,  medium-sized  sharp  retractors,  artery  forceps  and 
slender  clamps,  a  stout  probe,  periosteal  elevator,  "  keyhole  " 
or  other  narrow  saw,  [a  teaspoon  bent  at  right  angles  at  the 
junction  of  the  bowl  with  the  handle],  mouth-gag,  upper 
incisor  dental  forceps,  osteotome,  lion- jaw  bone  forceps,  ron- 
geurs, chisel,  mallet,  Volkmann  sharp  spoon,  needles,  needle 
holder,  ligatures,  sutures,  several  sponges  on  long  handles,  a 
few  squares  of  gauze  and  several  long,  narrow  strips  of  plain 
and  of  iodoformized  gauze. 

According  to  the  desire  of  the  operator,  the  assistant  ar- 
ranges the  patient  with  the  head  in  Rose's  position,  (i.  e., 
hanging,  face  upward,  over  the  end  of  the  table),  or  propped 
up  almost  vertically.  When  the  latter  position  is  adopted  the 
surgeon  may  decide  upon  preliminary  tracheotomy  (or  laryn- 
gotomy)  and  packing  of  the  pharynx,  and,  in  either  posi- 
tion, if  the  growth  be  very  vascular,  upon  placing  a  tem- 
porary ligature  upon  the  carotid. 

The  wound  assistant  compresses  one  coronary  artery  of  the 
upper  lip  (the  operator  compressing  the  other)  while  the 
primary  incision  is  being  made.  After  bleeding  vessels  have 
been  secured  and  the  cheek  flap  dissected  up  it  is  retracted 
in  a  piece  of  gauze  by  the  assistant,  who  may  make  pressure 
upon  it  if  there  be  much  oozing.  When  the  ala  of  the  nose  is 
detached  there  are  handed  to  the  surgeon  an  elevator  for 
freeing  the  periosteum  of  the  floor  of  the  orbit,  and  then  a 
"  keyhole  "  or  similar  saw  and  an  osteotome  for  dividing  the 


176  The  Surgical  AssistanI". 

malar  and  nasal  processes  of  the  superior  maxilla.  During 
these  manipulations  the  assistant  must  protect  the  eye  from 
injury,  and  if  an  orbital  elevator  is  needed  for  the  purpose 
the  bent  teaspoon  is  employed. 

The  mouth-gag  is  then  handed  and,  after  that,  dental  for- 
ceps for  extracting  an  upper  incisor  tooth.  Scalpel  and 
mouse-tooth  forceps  are  now  needed  for  incising  and  reflect- 
ing the  palate,  and  then  the  saw  and  bone  forceps  again  for 
dividing  the  palate  process.  Finally  chisel  and  mallet  and 
lion-jaw  forceps  are  needed  for  the  removal  of  the  bone,  a 
pair  of  scissors  being  laid  within  reach  of  the  wound  assistant 
to  separate  still  adherent  soft  parts.  A  sharp  spoon  may  also 
be  called  into  requisition  for  such  bone  or  tumor  particles  as 
do  not  come  away  with  the  mass.  It  is  during  the  last  steps 
of  the  operation  that  vigorous  sponging  out  of  the  pharynx 
especially  demands  the  assistant's  attention.  If  the  hem- 
orrhage continue  after  the  jaw  has  been  removed  the  iodo- 
formized  gauze  strips,  above  referred  to,  will  be  needed  for 
packing  the  cavity.  Silk,  catgut  or  other  sutures  are  handed 
for  closing  the  skin  wound.  A  light  gauze  dressing  should 
be  applied,  to  be  held  in  place  with  collodion,  adhesive  straps 
or  a  few  turns  of  a  bandage. 


CHAPTER   XIII. 

OPERATIONS  UPON  THE  THROAT,  NECK  AND  CHEST. 

OPERATIONS    UPON    THE   THROAT. 

The  Removal  of  Pharyngeal  Adenoids. — Assistance  at  this 
operation  consists  in  holding  the  patient  much  the  same  as 
for  a  throat  examination  as  previously  described  (fig',  i),  if 
no  anesthetic  is  to  be  given ;'  or  in  narcotizing,  and  in  spong- 
ing the  pharynx. 

The  assistant  should  protect  himself,  the  patient's  hair  and 
chest,  the  pillow,  the  floor  and  any  nearby  furniture  from 
the  blood  that  will  be  coughed  violently  from  the  throat.  A 
slop-pail  should  be  suitably  placed  at  the  upper  end  of  the 
table,  or  beside  the  bed,  as  the  case  may  be.  Several  sponges 
on  handles  and  an  abundance  of  towels  are  also  needed.  The 
implements  required  are:  mouth-gag,  [tongue  depressor], 
adenoid  forceps,  and  curette  (appendix,  fig.  56),  [head 
mirror  and  lamp]. 

It  is  well  to  repeat  here  that  before  assuming  the  respon- 
sibility of  administering  an  anesthetic,  the  assistant  should 
assure  himself  that  the  adenoid  growths  are  not  merely  a 
manifestation  of  a  status  lymphaticus.  Ether  is  to  be  pre- 
ferred. 

The  narcosis  should  not  be  very  deep,  yet  deep  enough  to 
last  through  an  operation  speedily  conducted,  after  the  mask 
is  removed.  When  the  patient  is  sufficiently  "  under,"  the 
mouth-gag  is  to  be  inserted  and  steadied  by  the  assistant's 
hand.  The  patient's  head  is  then  brought  over  the  end  of  the 
table  (Rose's  position) ,  or  to  the  edge  of  the  table  over  which 
it  can  be  turned  from  time  to  time  to  allow  the  blood  to  run 
from  the  mouth  into  the  pail.  The  pharynx  is  kept  clear  by 
sponging,  and  a  towel  should  be  held  in  readiness  to  receive 
blood  coming  from  the  nose. 

177 


178  The  Surgical  Assistant. 

Retropharyngeal  Abscess,  incised  by  the  buccal  route. 
The  head  shovild  hang  over  the  table,  bed  or  nurse's  lap,  in 
Rose's  position,  and  the  chest  should  be  freed  of  clothing. 
The  instruments  to  be  handed  are  a  gag,  a  sharp-pointed 
grooved  director  and,  for  opening  the  abscess,  a  narrow  scal- 
pel the  blade  of  which  is  to  be  protected  with  a  strip  of  adhes- 
ive plaster  wound  about  it  to  within  half  an  inch  of  the  point, 
or  a  pair  of  sharp-pointed  scissors  or  dressing  forceps.  In  an 
infant,  whose  small  pharynx  is  already  largely  occluded  by 
the  abscess,  the  introduction  of  a  finger  or  of  an  instrument, 
and  the  escape  of  pus,  are  very  apt  to  cause  suffocation  and 
cessation  of  breathing.  Whatever  wiping  of  the  throat  is  re- 
quired, therefore,  should  be  done  with  small  sponges  and 
very  quickly ;  and  the  assistant  should  be  ready  to  perform 
artificial  respiration.  Tracheotomy  is  rarely  required,  but  it 
is  wise  for  the  assistant  to  have  ready  a  few  clean  instru- 
ments for  its  performance. 

OPERATIONS    UPON    THE    NECK. 

The  technic  of  assistance  in  external  esophagotomy,  par- 
tial or  complete  thyroidectomy,  removal  of  diseased  glands 
or  nezv  groivths  in  the  neck,  operations  upon  cervical  blood- 
vessels or  nerves,  etc.,  follows  the  lines  laid  down  in  previous 
chapters.  The  patient's  neck,  or  neck  and  head,  should  be  so 
disposed  upon  a  pillow  that  the  particular  site  of  operation 
is  well  exposed,  but  the  anesthetist  must  see  to  it  that  this 
position  is  not  secured  at  the  expense  of  an  embarrassment 
of  the  patient's  respiration  by  distortion  of  the  trachea.  The 
assistant  should  seek  to  avoid  injury  to  any  nerves  or  blood- 
vessels with  sharp  retractors,  and  with  doubtful  structures 
at  any  rate,  he  should  allow  the  operator  to  decide  whether 
they  are  to  be  divided  as  bloodvessels  or  retracted  as  nerves. 
Softened,  diseased  glands  should  not  be  seized  with  mouse- 
tooth  forceps,  but  with  anatomical  forceps  or  with  the  fingers, 
lest  they  rupture  and  soil  the  surrounding  tissues.  If  a  drop 
of  pus  escape  from  a  gland  in  the  course  of  an  otherwise 
clean  dissection,  it  should  be  wiped  away  with  a  bit  of 


Tracheotomy.  179 

sponge,  and  the  neighboring  structures  are  to  be  protected 
with  gauze  against  further  danger  of  contamination.  As 
tumors  or  glands  are  being  dissected  out,  the  bloodvessels 
entering  them  should  be  clamped  before  the  operator  divides 
them.  It  is  wise  also  to  clamp  or  tie  the  last  strand  of  tissue 
by  which  the  growth  is  attached,  lest  it  contain  a  bloodvessel 
that,  retracting  into  the  deeper  tissues,  may  be  troublesome 
to  secure. 

The  dressing  after  an  operation  upon  the  neck  should  be 
neither  uneven  nor  bulky.  It  is  secured  by  circular  turns. 
If  the  wound  extends  far  down,  however,  the  banda/;e  should 
be  applied  in  figure  of  eight  turns  about  the  neck  and  chest 
crossing  posteriorly;  and  similarly  if  the  wound  extend  up- 
ward, turns  must  be  taken  about  the  head. 

Tracheotomy.  The  neck  should  be  well  extended  in  the 
median  line,  over  a  pillow.  While  in  emergency  the  opera- 
tion may  be  performed  with  nothing  more  than  a  pocket- 
knife  and  a  hairpin  or  a  piece  of  rubber  tubing,  when  it  is 
deliberately  undertaken  the  assistant  should  prepare  the  fol- 
lowing: scalpel,  two  mouse-tooth  forceps,  hemostats, 
medium-sized  and  small  sharp  retractors,  small  blunt  retrac- 
tor, curved  and  straight  scissors,  probe,  dressing  forceps, 
needles  and  needle  holder,  an  assortment  of  tracheal  tubes 
(appendix,  fig.  49),  and  the  dressing  described  below.  The 
soft  parts  should  be  retracted  symmetrically  after  the  incision 
is  made.  When  the  thyroid  isthmus  is  exposed  it  is  to  be 
drawn  upward  with  the  blunt  retractor.  Veins  crossing  the 
line  of  tracheal  incision  should  be  clamped  in  two  places, 
proximally  first,  and  divided  between.  After  the  trachea  is 
entered  the  wound  should  be  held  open,  with  the  small  retrac- 
tors, for  the  introduction  of  the  tube.  Sutures  may  be  de- 
sired, to  diminish  the  size  of  the  superficial  wound.  A  split 
compress  of  gauze  is  to  be  applied  over  the  wound,  and  sur- 
rounding the  canula,  which  latter  is  held  in  place  by  means 
of  tapes  tied  about  the  neck.  Over  the  mouth  of  the  tube 
should  be  placed  a  piece  of  moist  sea-sponge  or  gauze,  simi- 
larly held  with  tape.  Finally  a  bib  made  of  gauze  covered 
with  oiled  silk  should  be  applied  to  protect  the  upper  part  of 


180  The  Surgical  Assistant. 

the  chest  from  contact  with  mucous  discharges.  Turkey 
feathers,  trimmed  to  appropriate  size,  may  be  provided  for 
cleansing  the  tube  in  situ  of  accumulating  mucus. 

OPERATIONS    UPON    THE    CHEST. 

Breast  Amputation.  The  ordinary  instruments  for  dis- 
section and  hemostasis  are  all  that  need  to  be  prepared.  The 
patient  should  be  brought  to  lie  with  the  axillary  line  on  the 
affected  side  at  or  near  the  edge  of  the  table.  The  neck,  the 
arm,  and  the  chest,  anteriorly  and  posteriorly  over  a  wide 
area,  are  to  be  disinfected.  The  upper  extremity  from  the 
finger  tips  to  the  middle  of  the  arm  should  be  covered  with 
sterilized  towels,  pinned  in  place  or  fastened  with  a  sterile 
bandage,  and  given  into  the  hands  of  a  nurse  who  seats  her- 
self alongside  the  patient's  head.  The  wound  assistant 
should  stand  on  the  opposite  side  of  the  chest.  As  the  dissec- 
tion proceeds  from  place  to  place  he  should  move  his  retrac- 
tors, drawing  aside  the  skin  or  lifting  up  the  breast,  as  may 
be  required.  The  breast  must  not  be  drawn  out  too  forcibly, 
however,  lest  perforating  branches  of  the  internal  mammary 
and  intercostal  arteries  be  torn  off  short.  An  abundance  of 
artery  forceps  are  to  be  kept  within  easy  reach,  and  when  the 
assistant's  hands  are  not  otherwise  needed  he  should  tie 
clamped  vessels  in  order  to  maintain  the  supply  of  available 
hemostats.  When  the  breast  has  been  removed,  hot  pads 
are  usually  laid  upon  the  exposed  area.  Before  the  wound  is 
closed,  the  patient  is  to  be  turned  slightly  towards  the  sound 
side  in  order  that  a  short  drainage  tube  may  be  inserted, 
with  dressing  forceps,  into  an  opening  to  be  made  in  the  post- 
axillary  line. 

The  tension  sutures  usually  needed  vary  with  the  tastes 
of  different  operators.  While  they  are  being  tied,  the  flaps 
should  be  brought  together  with  the  flats  of  the  assistant's 
fingers.  Catgut  or  silk  sutures  (usually  continuous)  are  then 
to  be  passed  to  the  operator  for  closing  the  wound.  To  facili- 
tate the  application  of  the  dressing  the  patient  is  drawn  well 
out  beyond  the  table,  the  head  and  shoulders  being  supported 


Breast  Amputation. 


161 


by  assistants,  one  of  whom  should  hold  in  place  the  tube  and 
gauze  compress  applied  posteriorly.  The  dressing-  should  be 
in  the  form  of  large  pads  of  gauze,  supplemented  by  flat 
pads  of  absorbent  cotton  over  the  shoulder  and  neck   and  in 


Fig.  63.    Application  of  dressing  after  breast  operation. 

the  axilla.  The  bandages  should  not  be  narrower  than  four 
inches,  nor  wider  than  six.  Several  turns  are  first  to  be  made 
about  the  chest,  and  then  the  arm  is  to  be  included  as  far  as 
the  elbow. 

Empyema  Thoracis.     Diagnostic  Aspiration.     Unless  the 
pus  collection  is  presumed  to  be  localized  elsewhere  the  base 


18S 


The  Surgical  AssisxANt. 


of  the  chest  posteriorly  should  be  disinfected.  The  patient 
is  to  be  sat  upright,  as  a  rule,  supported  by  an  assistant's 
hands.  Small  children  may  be  held  against  the  chest  of  the 
assistant  and  facing  over  his  left  shoulder,  in  the  manner  de- 
scribed on  page  39. 

Before  handing  them  to  the  surgeon,  the  syringe  and 
needle  should  be  carefully  tested.  If  the  pus  is  not  to  be  im- 
mediately evacuated,  the  site  of  puncture  may  be  covered 
with  collodion  (see  page  308),  or  with  a  pledget  of  gauze 
fastened  by  means  of  adhesive  plaster. 


Fig.  64.    Position  of  patient's  chest  in  operation  for  empyema.    Rib  is  drawn 
up  'jvith  bone  hook,  by  assistant. 


Evacuation  by  Simple  Incision.  The  patient  is  to  be 
placed  upon  his  sound  side,  the  corresponding  arm  being 
drawn  slightly  forwards  from  beneath  the  trunk.  If  a  pillow 
is  slipped  under  the  chest  the  intercostal  spaces  on  the 
affected  side  will  be  the  better  extended.  The  instruments 
are  to  be  passed  in  this  order :  scalpel,  hemostats,  ligatures, 
curved  scissors,  sharp  retractors,  [mouse-tooth  forceps], 
dressing  forceps,  pus  basin,  drainage  tube.  As  the  pus  is 
being  evacuated,  the  anesthetist  should  be  alert  for  sudden 
embarrassment  of  the  respiration. 


Empyema  Thoracis.     Rib  Resection.  183 

Rib  Resection.  The  patient  should  be  placed  in  the  posi- 
tion just  described.  As  expediency  may  direct,  the  assistant 
may  face  the  patient  and  the  operator,  or  stand  behind  the 
patient  with  the  operator,  but  nearer  than  him  to  the  head  of 
the  table.  After  the  rib  is  exposed  and  its  periosteum  in- 
cised, an  elevator  or  raspatory  is  handed,  and  then  an  osteo- 
tome (costotome,  appendix,  fig.  74).  When  the  bone  has 
been  divided  at  one  site  the  cut  end  of  its  exposed  portion 
should  be  drawn  up  with  an  elevator,  a  bone  hook  or  a  re- 
tractor, to  facilitate  the  second  application  of  the  osteotome. 
Bone  hooks  and  retractors,  thus  used,  must  be  securely  ap- 
plied, for  if  they  slip  they  may  do  serious  injury  to  the  patient 
or  the  surgeons.  After  the  bone  has  been  removed,  scalpel, 
dressing  forceps  and  basin  are  to  be  handed,  as  in  the  opera- 
tion by  simple  incision. 

If  two  or  more  ribs  are  to  be  resected  the  assistant  observes 
the  same  method  of  procedure.  In  addition  he  should  pre- 
pare on  round  needles,  mass  ligatures  for  securing  intercostal 
vessels  in  continuity. 


CHAPTER  XIV. 

ABDOMINAL  OPERATIONS. 

The  disinfection  of  the  field  of  operation  and  the  arrange- 
ment of  the  tozvels  have  already  been  described.  As  an  addi- 
tional precaution  against  infection  of  the  wound  by  organ- 
isms in  the  skin,  a  saturated  solution  of  iodoform  in  ether 
may  be  poured  into  the  umbilicus  and  along  the  proposed  line 
of  incision.  This  solution,  it  may  be  noted,  will  form  a  blue 
stain  (iodid-of  starch)  wherever  it  is  allowed  to  come  in 
contact  with  a  towel.  The  application  of  the  Murphy 
rubber  dam,  or  of  Murphy's  gutta-percha  solution,  more 
perfect  means  of  protection  against  infection  from  the  skm, 
needs  no  special  description  here. 

ARMAMENTARIUM. 

In  addition  to  the  ordinary  dissecting  instruments,  and  to 
the  special  instruments  required  by  the  individual  case, 
there  should  be  ready,  retractors  of  appropriate  size  and 
shape,  sponges  on  handles,  and  several  gauze  packings  of 
various  widths.  It  is  well,  too,  to  have  at  hand  two  or  more 
clamps  (appendix,  figs.  44-46),  intestinal  sutures  and,  in 
any  case  where  the  intestines  are  apt  to  be  much  exposed, 
hot  pads.  In  cases  of  doubtful  nature,  an  aspirating  syringe 
should  also  be  provided. 

DISSECTION   OF  THE  ABDOMINAL  WALL. 

Incision  through  the  median  line. — After  the  superficial 
bloodvessels  have  been  clamped,  the  assistant  inserts  sharp 
retractors  in  the  skin  wound  and  then,  after  their  division,  in 
the  fascia  and  in  the  aponeurosis  (linea  alba).  In  this  way 
the  preperitoneal  tissues  and  the  peritoneum  are  exposed. 

184 


Abdominal  Operations. 


185 


If  the  aponeurosis  is  divided  just  to  one  side  of  the  linea 
alba,  i.  e.,  through  the  rectus  sheath,  the  assistant  employs 
his  retractors  in  a  manner  similar  to  that  described  below  for 
the  "  trap-door"  incision. 

Direct  incision  through  the  muscles. — The  assistant  is  to 
expose  each  tier  of  muscles  (external  oblique,  internal 
oblique,  transversalis),  in  order,  inserting  his  retractors  into 
the  layer  last  divided.  Vessels  should  be  clamped  as  they  are 
cut,  or  ligated  in  continuity  when  they  are  exposed  before 
division.  Nerves  that  can  be  spared  should  be  drawn  aside 
with  the  retractors. 

Intermuscular  dissection  (McBurney). — This  method  is 
employed  chiefly  for  the  removal  of  an  appendix  in  an  "  in- 
terval "  operation.    The  incision  through  the  skin  and  fasciae, 


Fig.  65.     "Trap-door  incision."    The  anterior  rectus  sheath  has  been  in- 
cised, and  is  retracted,  exposing  the  rectus  abdominis. 


made  parallel  with  the  direction  of  the  fibres  of  the  obliquus 
cxternus,  exposes,  with  the  aid  of  retractors,  that  muscle  it- 
self. After  it  has  been  divided,  by  blunt  dissection  along  the 
course  of  its  fibres,  the  sharp  retractors  should  be  inserted 


186 


The  Surgical  Assistant. 


into  it,  in  order  to  expose  the  obliquus  internus.  After  its 
division,  in  similar  manner,  the  retractors  are  shifted  to  this 
layer  and  placed  in  a  position  at  right  angles  to  their  former 
direction.  The  transversalis,  then  exposed  and  split,  is,  in 
turn,  to  be  drawn  aside,  the  retractors  now  occupying  a  posi- 
tion parallel  to  the  line  of  the  body  and  exposing  the 
peritoneum  by  a  transverse  slit. 

The  "  trap-door"  dissection  (known  also  as  the  Kammerer 
incision,  etc.). — The  outer  layer  of  the  rectus  sheath  is  seized 
by  the  forceps  of  the  operator  and  the  assistant  and  divided 
vertically, — the  skin  incision  being  usually  vertical  or  some- 


FlG.  66.  "  Trap-door  fncision."  The  belly  of  the  rectus  abdominis  is  drawn 
aside  with  a  blunt  retractor,  exposing  the  posterior  rectus  sheath.  The  skin 
retractor  on  the  same  side  of  the  wound  is  to  be  withdrawn. 


what  oblique.  This  aponeurosis  retracted,  there  is  exposed 
the  belly  of  the  rectus  abdominis  (figure  65)  which,  when 
freed  by  the  surgeon,  is  to  be  drawn  strongly  towards  the 
median  line  with  a  blunt  retractor  (figure  66),  and  the  skin 
retractor  on  the  same  side  is  released.  The  assistant  then 
picks  up,  opposite  the  grasp  of  the  operator,  the  posterior 
layer  of  the  rectus  sheath  for  incision  (figure  67)  ;  sharp  re- 


Abdominal  Operations. 


1S7 


tractors  are  now  inserted  into  this  divided  tissue,  and  the 
blunt  retractor  is  withdrawn.  The  parietal  peritoneum  is 
then  ready  for  incision. 

It  is  very  important  to  preserve  from  injury  nerve  fibres 
supplying  the  rectus,  if  they  are  exposed.     If  the  incision, 

Assistant's  right  hand. 


Fig.  67.    "Trap-door  incision."   Disposition  of  assistant's  hands  for  incision 
of  posterior  rectus  sheath  between  two  forceps. 

as  originally  made  or  as  subsequently  enlarged,  exposes  the 
deep  epigastric  vessels  beneath  the  rectus  muscle,  they  should 
be  drawn  aside  gently  by  the  assistant  or,  if  they  cannot  be 
thus  spared,  they  are  to  be  clamped  on  each  side  and  ligated 
in  continuity. 


188  The  Surgical  Assistant. 

opening  the  peritoneal  cavity. 

The  parietal  peritoneum,  exposed  by  one  of  the  above 
methods,  is  seized  with  tissue  forceps  by  the  assistant  oppo- 
site the  point  grasped  by  the  operator  and  lifted  away  from 
the  underlying  viscera.  If  there  be  much  intra-abdominal 
tension,  the  belly  wall  itself  should  be  lifted  up  with  the  re- 
tractors. After  a  small  nick  in  the  peritoneum  has  been  made 
between  the  two  forceps,  with  a  scalpel,  the  assistant  should 
continue  his  grasp  until  the  surgeon  has  transferred  his  for- 


SUR0E0N5  LEFT  HAND 


SURGEONS  RIGHT  HAND 


ASSISTANTS   UFT  HAND 


Fig.  68.  Enlarging  the  peritoneal  opening.  Assistant  prevents  injury  to 
underlying  viscera  by  depressing  them  with  blunt  scissors  and  lifting  the  belly 
wall  with  retractors. 

ceps  to  the  edge  of  the  opening.  This  the  assistant  may  then 
also  seize  on  the  opposite  side,  if  necessary.  A  pair  of 
straight,  blunt-pointed  scissors  with  which  to  enlarge  the 
opening  is  now  handed  to  the  operator.  It  may  be  necessary 
for  the  assistant  to  insert  just  under  the  peritoneum  a  pair 
of  blunt  scissors  or  a  similar  instrument  to  protect  the  viscera 


Abdominal  Operations. 


189 


from  injury  while  the  peritoneum  is  being  thus  further  in- 
cised (figure  68).  At  this  stage  of  the  operation  the  anes- 
thetist must  make  sure  that  the  patient  is  well  "  under," 
lest  intestine  or  omentum  be  strained  through  the  wound. 
In  any  case  a  narrow  packing  should  be  ready  for  introduc- 
tion to  restrain  protruding  gut. 

If  the  abdominal  wall  be  thick,  or  the  wound  be  small,  the 
assistant  may  attach  artery  forceps  or  guy  threads  to  the 
edges  of  the  peritoneum,  to  obviate  a  search  for  them  later 
on. 


Fig.  69.    Lifting  up  with  retractors  to  expose  to  view  a  large  visceral  surface 
through  a  relatively  small  opening. 


EXPOSING   THE   VISCERA. 


The  conditions  to  be  dealt  with  and  the  extent  and  location 
of  the  wound,  will  indicate  the  necessity  for  retractors  and 
the  shape  of  instrument, — large  or  small,  blunt  or  sharp, — 
best  suited.    Retractors  intelligently  handled  may  be  made  of 


190  The  Surgical  Assistant. 

great  assistance  to  the  operator ;  awkwardly  manipulated, 
they  are  more  a  hindrance  than  a  help.  Speaking  generally, 
.they  should  be  applied  symmetrically  and  drawn  upwards. 
Figure  69  illustrates  the  use  of  a  retractor  in  exposing  to 
view  a  large  surface  through  a  small  opening. 

PADS  AND  PACKINGS. 

The  gauze  packings  needed  during  a  laparotomy  should 
be  shaped  by  the  instrument  hander  not  only  according  to  the 
size  and  depth  of  the  wound,  but  also  with  reference  to  the 
purposes  for  which  they  are  intended,  viz. :  to  protect  exposed 
viscera,  to  "  wall  off  "  an  infected  area,  to  restrain  protrud- 
ing intestine,  or  to  serve  for  drainage.  To  cover  exposed 
tissues  the  packing  should  be  flat,  and  more  or  less  broad ;  to 
surround  an  abscess  or  similar  area  the  packings  should  be 
of  four  to  eight  thicknesses  of  gauze  and  of  about  the  same 
width  as  the  crevices  into  which  they  are  to  be  fitted ;  to  pre- 
vent the  protrusion  of  intestine  through  the  peritoneal  open- 
ing, the  packing  should  be  stout  and  folded  narrow  at  the 
end ;  for  drainage  the  gauze  should  be  folded  rather  narrow, 
as  a  rule.  If  used  in  the  form  of  a  wick  drain,  with  or  with- 
out the  rubber  tissue  cover,  the  packing  may  be  rolled  upon 
its  long  axis,  but  should  not  be  rolled  very  tightly.  When  it 
is  to  be  introduced  in  a  deep  or  narrow  cavity,  the  end  of  the 
drain  may  be  secured  in  a  dressing  forceps  and  handed  thus 
to  the  operator.  Used  for  drainage,  the  selvedge  may  be 
cut  from  the  gauze  strip,  but  this  is  not  essential.  Packings 
ought  to  be  free  of  raveled  edges  and  it  is  well  to  so  pre- 
pare them  that  a  folded  edge  is  deepest.  They  should  be 
handed  vertically,  with  a  pair  of  scissors  curved  on  the 
flat,  or  a  similarly  shaped  instrument,  for  introducing 
them.  (Figure  32.)  It  is  the  assistant's  responsibility  that 
no  foreign  bodies  be  left  unintentionally  in  the  abdominal 
cavity.  For  this  reason  packings  should  be  long  enough  to 
protrude  well  beyond  the  wound  or,  if  short,  they  must  each 
be  seized  with  a  clamp  to  be  left  hanging  on  the  belly.  Hot 
pads  are  likewise  to  be  clamped;  and  an  accurate  count  of 


Abdominal  Operations.  101 

pads  and  flat  sponges  (used  by  some  surgeons  in  a  manner 
similar  to  packings)  ought  to  be  registered  before  the  opera- 
tion is  begun  and  again  before  the  wound  is  closed. 

SUTURING  THE  ABDOMINAL  WALL. 

Through  and  through  sutures  are  ordinarily  of  stout 
silk  or  of  one  or  two  strands  of  silkworm-gut,  v/ith  or  with- 
out buttons.  They  are  mounted  on  long,  heavy,  curved 
needles.  When  the  needle  is  to  be  thrust  into  the  skin  the 
edge  of  this  tissue  should  be  steadied  with  the  operator's  or 
the  assistant's  mouse-tooth  forceps.  As  the  needle  is  about 
to  pierce  the  deeper  layers  of  the  belly  wall  the  assistant  with 
his  forceps  lifts  their  edges  from  their  retracted  position 
beneath  the  skin,  one  by  one  in  order,  and  brings  them  out  to 
the  level  of  the  skin  incision.  When  the  needle  is  transfixing 
the  opposite  side  of  the  wound  the  assistant  repeats  the  same 
maneuvers,  in  reverse  order  from  peritoneum  to  skin.  The 
ends  of  the  sutures  may  be  held  with  hemostats  until  all  are 
in  place.  When  the  sutures  are  to  be  tied,  or  secured  with 
buttons,  the  abdominal  wall  should  be  lifted  up  by  means 
of  the  suture  ends,  in  order  to  avoid  entanglement  of  intes- 
tine in  the  strands.  The  knots  are  brought  to  one  side  of  the 
wound.  The  skin  edges  are  then  adjusted,  superficial  sutures 
being  handed,  if  necessary,  to  secure  adaptation. 

Tier  sutures.  Assistance  should  be  rendered  as  follows  in 
the  introduction  of  layer  sutures  (alone  or  in  addition  to 
through  and  through  stitches).  A  running  catgut  suture 
on  a  small  needle  is  handed  to  the  operator.  Sharp  re- 
tractors are  inserted  In  the  abdominal  wall  just  superficial  to 
the  peritoneum,  the  free  edges  of  which  in  the  upper  angle 
of  the  wound  are  then  drawn  out  with  mouse-tooth  forceps 
first  on  the  side  furthest  from  the  surgeon,  then  on  the  other 
side.  Hooks  may  be  introduced  in  the  angles  of  the  perito- 
neal wound  to  put  the  edges  on  the  stretch,  but  this 
maneuver  is  not  ordinarily  required.  The  forceps  are 
moved  further  and  further  down  along  the  peritoneal  layer 
as  the  suturing  proceeds,  the  assistant  holding  the  last  stitch 
taut  until  the  next  stitch  is  introduced.     (See  pages  141- 143.) 


192  The  Surgical  Assistant. 

If  protruding  intestine  or  omentum  interfere  with  the  sew- 
ing a  packing  of  gauze  may  be  introduced  and  gradually 
drawn  out  again  as  the  peritoneal  edges  are  brought  to- 
gether. When  the  suture  is  finally  being  tied  any  pouting 
viscus  should  be  pushed  in  with  a  narrow  blunt  instrument. 
The  overlying  muscles  in  the  angles  of  the  wound  should 
then  be  lifted  up  to  make  sure  that  no  gap  in  the  peritoneum 
has  been  left  unclosed ;  after  which  the  suture  ends  are  cut 
short. 

The  deepest  muscular  or  aponeurotic  layer  {e.  g.,  the  pos- 
terior rectus  sheath)  is  next  exposed  by  shifting  the  re- 
tractors, and  its  edges  are  grasped  by  the  assistant's  forceps 
(or  prepared  for  the  operator's  grasp),  alternately  on  one 
side  and  the  other  from  above  downwards,  while  interrupted 
sutures  are  introduced  (chromicized  catgut,  silk,  silkworm- 
gut,  etc.)  on  short  stout  needles.  These  are  tied  at  once,  or 
"  cut  long  "  until  all  are  in  place.  The  next  muscle  layer 
is  similarly  handled.  A  catgut  suture  may  be  desired  for  the 
deep  fascia. 

If  the  intermuscular  dissection  has  been  made  no  suture 
may  be  needed  to  hold  the  split  fibres  in  apposition,  but  the 
running  catgut  stitch  may  be  continued  from  the  peritoneum 
along  the  muscle  layers,  one  after  the  other. 

Assistance  in  the  skin  suturing  has  been  described  (page 
143).  Instead  of  sutures  some  surgeons  use  narrow  strips 
of  sterile  (zinc  oxid)  adhesive  plaster  to  secure  coaptation 
of  the  skin  edges,*  Strips  of  various  widths  and  sealed  in 
envelopes  are  sold  for  this  purpose.  When  they  are  needed 
the  envelope  should  be  lifted  up  in  a  towel  by  the  assistant, 
and  one  end  of  it  cut  off  with  scissors.  The  inside  sterilized 
envelope  is  then  to  be  lifted  out  with  forceps, — and  the  towel, 
the  outer  envelope  and  the  scissors  are  to  be  laid  aside  as 
non-sterile.  Before  the  strips  are  applied,  the  wound  must 
be  well  dried  and  the  surrounding  skin,  if  moist  or  greasy, 
should  be  wiped  with  alcohol.  The  skin  edges  are  then  to 
be  adapted  while  the  strips,  handed  to  the  operator  one  by 
one,  are  laid  across. 


*  Lilienthal's  method. 


Abdominal  Operations.  19B 

THE  ABDOMINAL  DRESSING. 

The  towels  are  to  be  removed  from  the  abdomen  and  the 
skin  is  to  be  dried.  The  use  of  dusting  powders  (iodoform,* 
aristol,  etc.)  or  of  medicated  gauze  over  the  wound  is  a  mat- 
ter rather  of  individual  taste  on  the  surgeon's  part,  than  of 
essential  technic.  So,  too,  the  operator  may  or  may  not 
desire  next  to  the  wound  a  narrow  strip  of  steriHzed 
rubber  tissue,  to  obviate  adhesion  of  the  dressing  or,  more 
especially,  to  prevent  contamination  of  the  sutured  por- 
tion of  the  wound  by  pus  or  feces  that  is  expected  to 
be  discharged  through  a  drained  portion.  If  much  dis- 
charge is  to  be  provided  for,  loose  pieces  of  gauze  are 
first  laid  on,  either  dry  or  as  a  wet  dressing  covered  with 
rubber  tissue.  Otherwise,  a  small  flat  piece  of  gauze  is  ap- 
plied to  the  wound.  A  large  square  of  gauze  covers  the 
deeper  dressing,  and  is  to  be  held  in  place  by  ordinary  adhe- 
sive, or  by  "  laparotomy  "  straps. 

Laparotomy  straps  are  made  of  strips  of  adhesive  plaster 
about  two  inches  wide  and  eight  to  ten  inches  long.  One 
side  is  folded  upon  itself  for  a  distance  of  an  inch  and 
through  the  double  thickness  here  a  hole  is  cut  into  which 
an  end  of  a  piece  of  tape  twelve  inches  long  is  tied.  A 
piece  of  "  face  cloth,"  a  little  longer  than  the  adhesive  strap 
(so  that  it  can  be  easily  stripped  from  it),  is  kept  over  it 
until  the  strap  is  wanted.  Two  or  more  of  these  straps, 
according  to  the  size  of  the  dressing,  are  applied  symmetri- 
cally to  the  patient's  flanks,  and  their  corresponding  tapes 
are  tied  tightly  over  the  dressing.  A  double  turn  of  the 
tape,  as  in  the  surgeon's  knot,  secures  it  from  slipping  while 
the  second  (bow)  knot  is  being  made  (figure  70). 

In  lieu  of  laparotomy  straps  long  strips  of  adhesive  plaster 
may  be  passed  from  one  side  of  the  abdomen  to  the  other 
across  the  dressing.  They  are  to  be  drawn  tightly  from  the 
side  to  which  the  first  end  is  attached,  and  before  the  other 

*  Iodoform  crystals  are  less  apt  to  "  cake  "  and  occlude  the  orifices 
of  the  powder  sifter  than  is  powdered  iodoform. 


194 


The  Surgical  Assistant. 


end  is  fastened  down  the  skin  here  should  be  pushed  up  by 
the  flat  of  the  hand.  This  relieves  the  wound  of  much  ten- 
sion. The  same  thing  may  be  accomplished,  perhaps  a  little 
more  quickly,  by  applying  two  straps  at  a  time,  one  from  each 
side  of  the  abdomen  at  different  levels,  and  drawing  tightly 


Fig.  70.    Tying  laparotomy  straps. 


upon  each  as  they  are  simultaneously  crossed  over  the  abdo- 
men and  fastened  down  (figure  71). 

Over  the  straps  large  flat  pieces  of  gauze  are  to  be  placed, 
and  over  these  a  sheet  of  absorbent  cotton.  The  entire  dress- 
ing may  be  secured  by  means  of  a  bandage  or,  better,  with 
a  binder.  The  binder  is  to  be  rolled  up  half  across  its  width 
and  the  rolled  edge  slipped  under  the  patient.  While  the 
body  is  raised  to  accomplish  this,  the  back  should  be  quickly 
dried  with  a  towel  and  the  underlying  wet  sheets  withdrawn. 
The  ends  of  the  binder  are  then  overlapped  in  front  and 


Abdominal  Operations. 


195 


fastened  tightly  in  the  median  hne  with  a  row  of  safety  pins. 
For  slim  subjects  a  towel  may  be  thus  used  as  a  binder.  The 
Scultetus,  or  "  many-tailed,"  binder  is  to  be  similarly  applied, 


Fig.  71.    A  method  of  applying  adhesive  straps  over  the  abdominal  dressing. 

the  tails  being  overlapped  from  each  side  alternately,  the 
last  crossing  (or,  if  need  be,  several  crossings)  being  secured 
with  safety  pins. 


CHAPTER  XV. 

ABDOMINAL  OPERATIONS.— Continued. 

EXPLORATORY  LAPAROTOMY, 

The  assistant  must  consider  each  of  the  conditions  that  the 
lesion  may  prove  to  be  and  prepare  for  all  of  them.  Thus 
a  doubtful  tumor  may  be  a  mass  of  adhesions,  an  abscess, 
a  cyst,  a  new  growth  requiring  resection  of  the  intestine,  etc. 
For  exploratory  laparotomies  after  gunshot  and  crushing  in- 
juries he  should  prepare  hot  saline  solution,  hot  pads,  in- 
testinal sutures,  clamps  and  ligatures  for  the  removal  of  a 
ruptured  viscus,  etc. 

APPENDICITIS. 

"Interval  Operation."  Removal  of  the  Appendix  and 
Cauterisation  of  the  Stump.  The  wound  is  to  be  well  re- 
tracted and  packings  should  be  inserted,  if  necessary,  to  re- 
strain protruding  intestine,  while  the  operator  searches  for 
the  cecum  and  appendix  with  his  fingers  or  with  anatomical 
forceps.  The  appendix  found  and  drawn  well  out  of  the 
wound,  the  assistant  may  remove  his  retractors.  There  is 
then  handed  to  the  operator  a  double  strand  of  (number  two) 
catgut  mounted  in  a  ligature  carrier  or  pair  of  forceps. 
When  this  has  been  thrust  between  the  appendix  and  its  mes- 
entery the  assistant  seizes  it,  cuts  it  in  two  and  separates 
the  ends.  He  is  then  to  take  the  appendix  from  the  hand  of 
the  operator  and  hold  it  on  the  stretch,  so  that  one  of  the 
ligatures  can  be  tied  about  the  entire  mesentery  of  the  ap- 
pendix close  to  the  base.  [Two  or  more  ("chain")  liga- 
tures may  be  called  for  if  this  tissue  is  very  broad.] 

m 


Appendicitis;  Interval  Operation. 


197 


The  mesentery  thus  secured,  a  pair  of  scissors  is  passed 
for  amputating  it.  After  the  appendix  has  been  tied  with 
the  other  Hgature,  the  assistant  places  a  spht  compress  about 
the  base  of  it,  and  hands  a  small  clamp  (artery  forceps)  with 
which  to  secure  the  appendix  just  beyond  the  proposed  line 
of  amputation.  This  forceps  and  the  appendix  itself  the  as- 
sistant holds  while  the  surgeon,  drawing  upon  the  appendix 
ligature,  ablates  the  organ.  The  appendix,  the  attached 
forceps,  and  the  scissors  are  at  once  dropped  into  a  specimen 
dish  or  towel  and  discarded  as  "  soiled."     If  the  Paquelin 


Fig.  72.    Gauze  packing  inserted  and  cecum  drawn  into  the  wound. 


cautery  is  to  be  used  to  disinfect  the  stump,  there  should 
be  handed  to  the  operator  a  sterile  towel  in  which  to  receive 
the  handle  of  the  instrument.  Pure  carbolic  acid  may  be 
used  with  equal  effect  and  greater  convenience, — the  tip  of  a 
probe  or  closed  dressing  forceps  is  dipped  into  the  phenol 
and  excess  of  the  fluid  is  allowed  to  drip  ofif.  The  appendix 
thus  treated,  the  split  compress  is  to  be  removed  and  the  liga- 
ture ends  ablated. 


198  The  Surgical  Assistant. 

Removal  of  the  Appendix  and  Inversion  of  the  Stump. 
Here  the  assistant  hands  only  a  single  ligature  for  the  mesen- 
tery. Then  he  provides  a  fine  catgut  or  silk  suture  in  a  small 
needle  to  be  passed,  purse-string  fashion,  about  the  base  of 
the  appendix.  Split  compress,  clamp  and  scissors  are  then 
needed  as  in  the  other  method ;  and  soiled  instruments  are 
afterwards  removed  in  the  same  manner,  with  the  appen- 
dix.    A  probe  is  next  handed  to  test  the  patency  of  the  lumen 


Fig.  73.  Assistant  lifting  up  appendix  while  the  operator  inserts  double 
ligature. 

of  the  appendix  stump.  The  probe  is  then  discarded.  The 
assistant  now  thrusts  in  the  mucous  membrane  of  the  stump 
with  mouse-tooth  forceps  while  the  surgeon  ties  the  purse- 
string  suture;  after  which  the  forceps  thus  used  are  dis- 
carded. The  split  compress  is  removed  and  a  fine  silk  suture 
is  handed  for  sewing  over  the  stump  (Lembert  suture). 

Appendicitis  with  Abscess.  The  scrubbing  of  the  abdo- 
men should  be  performed  gently.  The  assistant  prepares  in 
advance  several  packings,  of  various  widths,  and  a  generous 
supply  of  bits  of  sea-sponge.    These  bits  may  be  mounted  on 


Appendicitis:  Abcess. 


199 


hemostats  or  left  in  a  dish  from  which  they  are  to  be  lifted, 
as  needed,  with  thumb  forceps.  The  location  of  the  abscess 
determines  the  site  of  incision  and  the  method  of  dissection, 
and  the  assistant  will  follow  the  movements  of  the  operator, 
in  these  cases,  rather  than  proceed  along  any  very  exact  line 
of  technics.  Packings  will  probably  be  required  until  the 
abscess  is  reached  and  again  after  it  is  opened,  to  protect  the 
surrounding  tissues.  The  sponges  must  be  in  readiness  for 
the  first  sign  of  pus  and  the  assistant  should  manipulate  them 
quickly,  but  with  care  not  to  scatter  infectious  material  with 


Fig.  74.    Amputation  of  appendix.    Ligatures,  clamp  and  split  compress  in 
place. 


them.  If  the  appendix  is  to  be  removed  the  assistant  follows 
the  technics  described  above — modified,  however,  according 
to  the  condition  of  the  organ.  Cauterization  of  the  stump 
is  not  required.  While  the  operator  may  require  gauze 
alone  for  drainage  it  is  v/ell  to  have  a  drainage  tube  in  read- 
iness, also. 


200  The  Surgical  Assistant, 

general  peritonitis. 

From  Appendicitis  or  Other  Cause.  The  duties  required 
of  the  assistant  are  much  the  same  as  in  abscess  operations. 
The  use  of  irrigating  solutions,  drainage  methods,  etc.,  is 
a  matter  of  individual  technics.  Deep  collections  of  pus  re- 
quire removal  by  sponges  on  long  handles.  If  the  operator 
decides  upon  opening  one  or  more  coils  of  distended  intes- 
tine, the  assistant  surrounds  the  selected  portion  of  gut, 
drawn  well  out  of  the  abdomen,  with  hot  towels.  A  scalpel, 
trocar  or  aspirating  needle  is  handed  for  puncturing  the 
intestine,  and  a  pus  basin  is  held  beneath.  A  silk  suture 
will  be  needed  to  close  the  opening.  As  a  matter  of 
surgical  cleanliness  the  assistant  should  rinse  his  hands 
after  this  procedure,  and  spread  fresh  towels  about  the 
wound. 

Lavage  of  the  Stomach  before  the  operation  may  be  re- 
quired of  the  assistant  when  there  has  been  a  great  deal  of 
vomiting.  If  this  is  done  while  the  patient  is  anesthetized  a 
gag  should  be  introduced  into  the  mouth.  A  rubber  tube 
about  thirty  inches  long  is  connected  at  one  end  to  a  large 
(preferably  glass)  funnel,  and  at  the  other  end,  by  means  of 
a  glass  canula,  to  the  stomach  tube.  The  latter  is  to  be  dipped 
in  water  and  then  passed  to  the  posterior  wall  of  the  pa- 
tient's pharynx  and  guided  into  the  esophagus.  Many  tubes 
are  marked  to  indicate  the  proper  length  to  be  inserted 
(about  fourteen  inches),  and  often  regurgitation  through 
the  tube  will  indicate  that  the  stomach  has  been  reached. 
If  efforts  at  vomiting  are  induced  by  the  introduction  of  the 
tube  the  funnel  should  be  held  down  over  the  edge  of  a 
slop  pail  on  the  floor  to  allow  drainage  of  the  stomach  con- 
tents through  the  tube.  The  funnel  is  then  to  be  filled  and 
held  above  the  level  of  the  patient's  head.  Before  it  is  en- 
tirely empty  it  is  filled  again,  and  this  is  repeated  until  about 
a  quart  of  warm  water  or  warm  saline  solution  is  poured 
into  the  stomach.  Before  all  the  water  has  left  the  funnel 
the  latter  is  depressed  into  the  slop  pail,  thus  siphoning 
out  the  material  in  the  stomach.     This  procedure  is  to  be 


Gastric  Lavage.  201 

repeated  until  the  water  returns  clear.  If  necessary,  in- 
termittent manual  pressure  over  the  stomach  may  be  em- 
ployed to  help  in  emptying  it.  As  in  gavage,  the  tube  may 
be  introduced  through  the  nose  when,  for  any  reason,  the 
mouth  is  ineligible. 


CHAPTER  XVI. 

ABDOMINAL  OPERATIONS.— Continued. 

OPERATIONS    UPON    THE    GALL-BLADDER   AND    GALL   DUCTS. 

CJwlecystostojiiy,  Cholccystotouiy.  Long  stout  probes 
and  sounds,  stone  spoons  and  forceps,  clamps  and  ligatures 
for  adhesions,  an  aspirating  syringe,  sponges  on  handles,  a 
pus  basin,  drainage  tubes  and  gauze  packings,  should  be  in 
readiness,  and  in  a  case  of  empyema  of  the  gall-bladder  ir- 
rigating solution  should  also  be  at  hand.  The  assistant  will 
aid  in  exposing  the  gall-bladder  by  the  use  of  retractors 
placed  in  the  abdominal  wall  and,  if  necessary,  a  large  one 
under  the  edge  of  the  liver.  Stout  catgut  ligatures  are 
handed  for  tying  adhesions,  and  torn  adhesions  should  be 
covered  by  the  assistant's  sponges  to  prevent  oozing  of  blood 
into  the  abdominal  cavity ;  packings  will  be  needed  for  cover- 
ing exposed  intestine  and  for  surrounding  the  gall-bladder. 
P'or  cholecystostomy  a  running  catgut  suture  on  a  small, 
round,  full-curved  needle  will  be  required  for  attaching  the 
gall-bladder  to  the  parietal  peritoneum.  If  the  abdominal 
wall  is  thick  the  surgeon  will  probably  desire  first,  however, 
a  few  interrupted  catgut  sutures  to  fasten  the  parietal  perito- 
neum to  the  subcutaneous  tissues.  The  gall-bladder  thus 
fastened,  a  narrow  strip  of  gauze  is  handed  for  further  clos- 
ing off  the  abdominal  cavity  at  the  circumference  of  the  ex- 
posed area  of  the  fundus  of  the  gall-bladder.  If  the  opera- 
tion is  to  be  conducted  in  two  sittings  the  assistant  now 
hands  a  loose  gauze  pad  for  covering  the  wound,  and  the 
usual  outer  dressings.  If  the  operation  is  to  be  concluded 
at  once,  however,  the  assistant  will  act  next  according  as  to 
whether  the  gall-bladder  contains  chiefly  stones  and  very 
little  fluid  or  is  distended  with  fluid   (hydrops,  empyema). 

»03 


Cholecystostomy, 


203 


In  the  first  case  he  will  hand  scalpel  and  mouse-tooth  forceps 
for  opening  the  viscus,  forceps  and  spoons  for  removing 
stones,  sound  for  probing  the  ducts,  tube  for  drainage,  [cat- 
gut gall-bladder  suture],  and  dressing.  In  the  second  case 
an  aspirating  syringe  having  first  been  handed  for  determin- 
ing the  contents  of  the  bladder,  the  assistant  turns  the  pa- 
tient so  that  he  lies  on  his  right  side  near  the  edge  of  the 
table,  covering  meanwhile  with  a  sponge  or  pledget  of  gauze 
the  needle  hole  in  the  bladder.     A  "  bib  "  of  sterilized  rub- 


FiG.  75.    Assistant  holding  patient  on  his  side  while  contents  of  gall-bladder 
flow  into  pus  basin. 


ber  tissue  is  then  placed  over  the  lower  portion  of  the 
wound  and  tucked  into  its  angles,  to  prevent  soiling  of  the 
tissues.  A  pus  basin  being  held  in  position,  scalpel  and 
dressing  forceps  are  passed  to  open  the  gall-bladder. 
One  or  two  drainage  tubes  will  next  be  needed  through 
which  to  irrigate  the  viscus,  and  after  these  stone  forceps 
and  sounds. 


S04  The  Surgical  Assistant. 

When  cholecystotomy  is  performed  sutures  of  catgut,  to 
close  the  mucous  membrane,  and  of  silk  for  the  peritoneal 
covering  of  the  gall-bladder,  are  to  be  ready. 

Choledochotomy.  Retractors,  wide  and  narrow  gauze 
packings,  and  ligatures  for  adhesions  will  be  needed  much 
as  for  cholecystostomy.  If  the  common  duct  is  being  at- 
tacked there  should  be  handed  two  guy  sutures  to  secure  it 
on  each  side  of  the  proposed  line  of  incision ;  then  scalpel  and 
narrow-bladed  stone  forceps ;  then  another  suture  of  plain  or 
chromic  catgut,  on  a  small  hemostatic  needle  in  a  slender 
holder,  if  the  duct  is  to  be  sewed  ;  then  a  drain  of  gauze,  or 
of  rubber  tubing  to  be  surrounded  by  narrow  gauze  pack- 
ings. For  the  partial  closing  of  the  wound  "  through  and 
through  "  sutures  of  silk  or  silkworm-gut  will  probably  be 
all  that  are  demanded.  It  is  important  during  an  operation 
upon  the  common  bile  duct  that  the  anesthetist  keep  the  pa- 
tient well  "  under,"  and  yet,  because  of  the  great  shock  of 
the  operation,  that  he  administer  no  more  of  the  anesthetic 
than  is  really  necessary. 

Cholecystectomy.  The  gall-bladder  and  cystic  duct  must 
be  well  exposed  by  retracting.  As  the  bladder  is  being 
stripped  from  the  liver  and  from  surrounding  adhesions 
by  means  of  blunt,  curved  scissors  the  bleeding  surfaces 
must  be  sponged,  actively  but  gently.  The  stripping  pro- 
cess completed,  a  stout  catgut  ligature  is  to  be  handed  for 
the  cystic  duct.  This  ligature  the  assistant  will  probably 
be  called  upon  to  tie  (while  the  operator  holds  it  in  the  posi- 
tion he  desires  and  lifts  up  the  bladder).  All  surrounding 
tissues  being  now  protected  with  gauze,  a  right-angled, 
curved  clamp  ("gall-bladder  clamp")  is  handed,  to  secure 
the  neck  of  the  viscus,  which  is  then  amputated  with  scissors, 
the  assistant  drawing  gently  on  the  duct  ligature.  Scissors 
and  gall-bladder  are  received  in  a  specimen  dish,  and  there 
is  handed  a  Paquelin  cautery,  or  an  instrument  dipped  in 
pure  carbolic  acid,  with  which  to  treat  the  stump.  A  cig- 
arette drain  of  length  sufficient  to  reach  the  stump  will  be 
required  next.  The  temporary  packings  removed,  sutures 
are  handed  for  closing  the  wound. 


Operations  Upon  the  Liver.  203 

operations  upon  the  liver. 

Cyst  of  the  Liver;  Abscess  of  the  Liver,  opened  ante- 
riorly. 

The  liver  exposed,  an  aspirating  syringe  with  a  long 
stout  needle  will  be  required  to  explore  it.  If  fluid  of  a 
doubtful  character  is  drawn  into  the  syringe  there  should  be 
handed  a  white  dish  into  which  the  material  may  be  thrown 
for  closer  scrutiny,  the  assistant  meanwhile  holding  his  fin- 
ger over  the  end  of  the  needle  projecting  from  the  liver. 
When  the  abscess  or  cyst  has  been  located  the  surgeon  may 
decide  to  empty  it  at  a  later  occasion  or  to  finish  the  opera- 
tion at  once.  In  the  first  case  sutures  or  gauze  packings, 
or  both,  are  needed  to  close  off  the  abdominal  cavity,  as  in 
operations  for  empyema  of  the  gall-bladder ;  a  ring  of  gauze 
is  placed  about  the  needle  to  support  it  in  position ;  and  a 
light  dressing  is  applied.  In  the  second  case,  after  packings 
are  inserted  all  about  the  exposed  liver  surface,  alone  or  in 
addition  to  a  line  of  sutures,  a  long  dressing  forceps  is  to 
be  handed  with  which  to  open  the  cavity  along  the  path  of 
the  needle.  The  needle  is  removed  and  there  are  provided 
one  or  two  large  drainage  tubes,  through  which  the  opera- 
tor may  wish  to  irrigate.  A  split  compress  and  an  abundant 
dressing  of  loose  gauze  should  be  applied. 

Cyst  of  the  Liver;  Abscess  of  the  Liver;  Sub-phrenic 
Abscess,  opened  posteriorly. 

The  patient  is  placed  on  his  left  side.  Instruments  are 
passed  the  same  as  in  rib  resection  for  empyema  thoracis 
(q.v.).  If  during  the  dissection,  the  pleural  cavity  be  in- 
vaded the  assistant  should  at  once  place  a  finger  over  the 
opening  until  a  suture,  which  should  be  ready  for  such  an 
inadvertence,  can  be  inserted  and  the  suture  line  covered 
with  a  plug  of  gauze.  Mouse-tooth  forceps  and  scalpel 
are  needed  for  incising  the  diaphragm.  The  remaining  steps 
of  the  operation  the  assistant  provides  for  as  described  for 
the  anterior  route. 

Resection  of  the  Liver  (New  growth).  The  chief  duties 
of  the  assistant  here  lie  in  exposing  and  sponging  the  field, 


206  The  Surgical  Assistant. 

in  properly  protecting  surrounding  viscera,  and  in  provid- 
ing for  hemostasis.  For  the  latter  there  will  be  needed 
slender  clamps,  the  Paquelin  cautery,  ligatures,  hemostatic 
sutures  in  round,  half-curved  needles,  and  several  narrow 
packings.  In  addition  to  these  articles,  and  to  the  usual 
preparations  for  laparotomy  there  should  be  ready  instru- 
ments for  rib  resection  (page  183),  pedicle  ligatures,  aspirat- 
ing syringe  and  sutures  to  attach  the  liver  to  the  margin  of 
the  abdominal  wound. 


CHAPTER  XVII. 

ABDOMINAL  OPERATIONS.— Continued. 
OPERATIONS    UPON   THE   STOMACH  AND   INTESTINES. 

GASTROSTOMY. 

If  practicable  the  stomach  should  be  washed  out  before 
the  operation  (page  200). 

The  assistant  stands  on  the  left  side  of  the  patient's  abdo- 
men, relaxation  of  which  is  increased,  if  need  be,  by  eleva- 
tion of  the  knees  and  shoulders.  The  abdominal  wall  hav- 
ing been  divided,  by  vertical  or  oblique  incision,  the  as- 
sistant inserts  retractors  to  facilitate  the  search  for  the  stom- 
ach. A  retractor  may  be  required  to  elevate  the  overlapping 
area  of  the  liver.  The  stomach  brought  up  into  the  wound, 
packings  will  be  needed  to  surround  the  portion  in  which 
the  opening  is  to  be  made.  In  addition  an  assistant's  hand, 
gloved  or  covered  with  gauze,  will  probably  be  needed  to 
hold  the  anterior  surface  of  the  stomach  in  proper  position. 

The  Witzel  Method.  Forceps  and  scissors  are  handed, 
with  which  to  make  a  small  opening  near  the  cardiac  end  of 
the  stomach.  Into  this  is  to  be  snugly  fitted  one  end  of  a 
piece  of  red  rubber  tubing  six  or  eight  inches  long  and  of 
about  the  diameter  of  a  stomach  tube,  which  the  assistant 
now  provides.  Next  will  be  needed  several  fine  silk  sutures 
with  which  to  sew  together  over  the  tube  the  folds  of  the 
organ  on  each  side  of  it.  While  these  stitches  are  being  in- 
troduced and  tied,  the  assistant  holds  the  tube  in  the  opening 
and  flat  against  the  stomach.  After  that  he  hands  a  run- 
ning catgut  suture  to  unite  the  parietal  peritoneum  on  each 
side  of  the  wound  to  the  visceral  peritoneum  about  the  tube. 
A  clip  is  then  to  be  placed  on  the  free  end  of  the  drain,  and 
loose  gauze  applied  around  it,  to  be  held  in  place  with  ad- 
hesive straps  and  a  bandage. 

207 


208  The  Surgical  Assistant. 

The  Marwedel  Method.  A  suture  having  been  handed  to 
fasten  the  stomach  to  the  free  edges  of  the  parietal  peri- 
toneum, scissors  or  scalpel  are  needed  for  incising  the  serous 
and  muscular  coats.  Then  a  narrow,  blunt,  periosteal  eleva- 
tor or  similar  instrument  will  be  required  to  strip  the  mucous 
membrane  from  the  superficial  coats  for  a  short  distance  be- 
yond the  opening.  The  tube  will  then  be  slipped  into  this 
canal,  and  a  suture  is  needed  to  hold  it.  Instead  of  this  the 
operator  may  incise  the  outer  coats  and  separate  them  by 
direct  dissection,  sewing  them  together  again  over  the  tube. 

The  Kader  Method.  A  running  suture  is  to  be  handed 
for  attaching  the  stomach  to  the  abdominal  wall.  A  tube  is 
needed,  as  in  the  other  method,  to  be  held  vertical  after  being 
inserted  in  its  opening,  while  concentric  running  sutures  of 
silk  are  stitched  about  it  and  drawn  tight. 

Albert  and  S sabanijezvs-Franck  Methods.  The  assistant 
holds  a  large  cone  of  the  anterior  wall  of  the  stomach  pro- 
jecting through  the  wound,  while  the  operator  attaches  the 
base  of  the  cone  to  the  parietal  peritoneum  and  posterior  rec- 
tus sheath.  A  scalpel  is  then  to  be  handed  for  making  a 
second  skin  incision  and  for  dissecting  up  the  skin  between 
this  point  and  the  larger  wound.  Forceps  are  passed  to 
draw  the  apex  of  the  cone  through  this  subcutaneous  chan- 
nel, and  then  scissors  and  a  few  stitches  to  open  this  apex 
and  fasten  it  in  place.  Sutures  are  next  required  to  close 
the  large  wound. 

Internal  Esophagotomy,  after  gastrotomy  or  gastrostomy. 
For  this  there  are  to  be  prepared,  in  addition  to  the  usual 
instruments,  a  pair  of  long  slender  dressing  forceps,  an 
assortment  of  fine  and  stouter  esophageal  bougies,  several 
long  strands  of  silk  of  various  thicknesses  [and  a  mouth- 
gag]. 

GASTRORRHAPHY     AFTER     PERFORATION     OF     THE     STOMACH. 
ENTERORRHAPHY  AFTER   PERFORATION   OF   THE   INTESTINE. 

There  should  be  at  hand  several  gauze  packings  and  hot 
pads,  sponges  on  handles  for  mopping  out  infectious  ma- 
terial, hot  salt  solution  for  irrigation,  drainage  tubes,  and 


Intestinal  Operations.  -      209 

several  fine  silk  sutures.  The  wound  should  be  well  retracted 
while  a  search  is  being  made  for  the  perforation.  When  this 
is  found,  the  assistant  must  be  ready  with  a  small  sponge  to 
check  the  escape  of  fluids,  and  with  packings  to  wall  off  the 
area  to  be  treated.  The  immediate  neighborhood  of  the  per- 
foration having  been  cleansed,  and  the  affected  portion  of  the 
viscus  being  steadied  in  the  wound,  the  silk  sutures  are  next 
required.  When  the  perforation  has  been  satisfactorily 
closed  over,  sponges  will  be  needed  to  wipe  out  infected 
pockets  among  the  intestinal  coils,  which  are  to  be  exposed 
systematically,  one  after  the  other.  The  conditions  present 
will  demonstrate  the  need  or  otherwise  for  irrigation  and  the 
provisions  to  be  made  for  drainage. 

gastro-enterostomy ;  gastrectomy;  pyloroplasty; 
pylorectomy. 

The  assistant's  preparations  for,  and  technics  in,  these 
operations  are,  for  the  most  part,  the  same  as  for  intestinal 
anastomosis  and  resection  (q.  v.) ;  and,  for  the  rest,  his 
manipulations,  e.  g.,  the  holding  and  exposing  of  the  stomach 
and  the  gut,  etc.,  are  indicated  to  him  by  the  operator's 
methods.  Plastic  operations  require  that  several  medium- 
fine  silk  sutures  be  prepared  in  advance,  with  straight 
(cambric)  or  with  small,  full-curved  needles,  or  with  both. 
Clamps  similar  to,  but  longer  than,  those  used  for  the  intes- 
tine, are  employed  upon  the  stomach  in  resecting  that  viscus. 

COLOSTOMY. 

Inguinal  Colostomy.  The  division  of  the  abdominal  wall 
completed,  bleeding  vessels  ligated,  and  the  intra-abdominal 
conditions  surveyed,  the  assistant  draws  out  the  free  margins 
of  the  parietal  peritoneum  for  the  surgeon  to  secure  this 
tissue  to  the  skin  edge  of  the  wound  with  a  running  catgut 
suture.  While  this  is  being  done,  a  gauze  compress  may  be 
needed  to  prevent  bulging  of  the  intestine  through  the 
wound.  The  desired  portion  of  the  colon  having  been  de- 
livered into  the  opening,  packings  may  again  be  needed,  both 
to  support  this  gut  temporarily  and  to  restrain  other  coils. 


210 


The  Surgica.l  Assistant. 


To  ensure  the  presence  of  an  ample  "  spur,"  a  glass  rod, 
metal  sound  or  similar  instrument  may  next  be  required. 
The  assistant  with  both  hands  draws  the  segment  of  colon 
well  out  of  the  abdomen,  while  the  operator  thrusts  the  rod 
through  the  meso-colon  close  to  its  junction  with  the  intes- 
tine. Interrupted  silk  sutures  are  now  to  be  handed  to  the 
surgeon  for  fastening  the  circumference  of  the  presenting 
portion  of  colon  and  the  meso-colon  to  the  everted  margin 
of   the  parietal  peritoneum,  the  assistant  gently   drawing 


Fig.  76.  Inguinal  Colostomy.  Rod  in  place.  Manipulation  for  anchorage 
of  visceral  to  parietal  peritoneum. 

first  one  portion  of  the  gut  and  then  another  upwards  and 
towards  the  center  of  the  wound  as  the  stitches  are  put  in 
place  and  cut  short. 

If  the  intestine  is  to  be  opened  at  once  a  gauze  strip  should 
be  tucked  about  its  base.  The  patient  is  then  turned  upon 
his  side,  and  a  pus  basin  held  in  place  to  receive  the  fecal 
discharge.  Forceps,  and  scissors  or  scalpel  are  handed  to  the 
operator  and  after  these,  if  needed,  a  long  drainage  tube. 
Irrigation  of  the  colon,  by  means  of  a  piston-  or  fountain- 
syringe,  may  be  desired.  The  parts  are  then  to  be  cleansed 
and  the  skin  about  the  wound  is  to  be  freely  anointed  with 
vaselin.  The  dressing  consists  of  a  ring  of  gauze  surround- 
ing the  wound,  and  abundant  loose  gauze  above  it. 


Intestinal  Resection.  211 

If  the  intestine  is  not  opened  at  once,  a  good-sized  tea- 
strainer  may  be  inverted  over  it,  the  metal  rim  resting  on  a 
ring  of  gauze — to  prevent  pressure  upon  the  gut  by  the  sup- 
erimposed layers  of  gauze. 

Lumbar  Colostomy.  The  patient  is  placed  on  his  side — 
usually  on  the  right  side — with  a  cylindrical  cushion  under 
the  lower  loin.  Instruments  are  passed  for  dividing  and  re- 
tracting the  skin  and  muscles.  Ligatures  should  be  handed 
for  tying  all  the  clamped  vessels  before  the  colon  is 
sought  for.  After  the  perinephric  fat  has  been  torn  through 
it  is  to  be  retracted  by  the  assistant.  If  the  kidney  obstructs 
the  route  to  the  gut,  the  assistant  should  hold  it  aside  with 
his  fingers.  The  (posterior  surface  of  the)  colon  delivered 
into  the  wound,  stout  sutures  of  [chromicized]  catgut  are 
next  needed  for  anchoring  it  to  the  skin.  If  the  meso-colon 
is  sufficiently  long,  a  rod  may  be  desired  to  support  the 
colon,  as  described  above,  before  the  sutures  are  introduced. 

The  opening  and  drainage  of  the  gut,  and  the  dressing  of 
the  wound,  are  as  in  inguinal  colostomy. 

INTESTINAL   RESECTION. 

Hot  pads  and  salt  solution,  sponges  on  handles  and  a 
variety  of  gauze  packings,  should  be  at  hand.  Several  silk 
sutures  on  fine  curved  and  straight  cambric  needles  are  to 
be  prepared,  and  a  supply  of  catgut  ligatures  should  also  be 
cut  in  advance.  In  addition  to  the  usual  instruments  for  dis- 
secting, a  few  straight  clamps  should  be  provided  and  either 
intestinal  clamps  or  two  strips  of  gauze  or  of  rubber  tub- 
ing. Murphy  buttons  or  similar  devices  may  be  used  by  the 
operator,  and  should  be  made  ready,  if  provided. 

When  possible,  the  segment  of  gut  to  be  resected  is  usually 
drawn  outside  of  the  abdomen  and  surrounded  by  hot  towels. 
Before  this  can  be  accomplished  it  may  be  necessary  to 
supply  clamps  and  ligatures  to  separate  adhesions.  The 
assistant  lifts  up  several  inches  of  the  intestine  on  the  prox- 
imal side  of  the  area  to  be  excised,  while  the  operator 
"  milks "  its  contents  out  of  it  and  thrust?  through  th^ 


212  The  Surgical  Assistant. 

mesentery,  five  or  six  inches  from  the  hne  of  division,  an  in- 
testinal clamp  or  strip  of  gauze  and  secures  the  intestine  in 
this.  The  distal  segment  is  then  similarly  lifted  up,  emptied 
and  secured.  Instead  of  by  gauze  or  clamps,  the  escape  of 
feces  may  be  prevented  by  digital  compression  of  the  intes- 
tine if  an  assistant  can  be  spared  for  this  purpose.  The 
mesentery  is  then  to  be  spread  out,  and  mounted  ligatures 
handed  to  secure  its  vessels.  After  the  mesenteric  wedge 
has  been  cut  away  with  scissors,  large  gauze  compresses  are 
to  be  placed  under  the  intestine.  Two  clamps  will  then 
probably  be  desired  for  application,  one  at  each  line  of  sec- 
tion. As  the  gut  is  cut  through  on  each  side,  the  assistant 
should  so  manage  the  open  ends  that  all  the  escaping  con- 
tents fall  upon  the  gauze.  The  resected  tissue  is  received  in 
a  basin  and  removed.  With  thumb  forceps  the  assistant  lifts 
up  and  holds  open  first  one  and  then  the  other  segment  of 
intestine  while  the  surgeon  wipes  it  out  with  sponges  on 
handles,  which  are,  of  course,  to  be  at  once  discarded. 

The  soiled  gauze  having  been  removed,  the  assistant  now 
rinses  his  hands  and  spreads  fresh  compresses  in  preparation 
for 

INTESTINAL   ANASTOMOSIS. 

(i)  By  Circular  Entcrorrhaphy.  Six  to  eight  "anchor- 
age sutures"  of  medium-sized  silk  on  straight  (cambric) 
needles  are  first  needed.  With  mouse-tooth  forceps  the 
assistant  picks  up  the  edge  of  the  open  end  of  each  section 
of  gut  at  its  mesenteric  side  in  such  a  manner  that  the 
mucous  membrane  is  everted.  This  facilitates  the  introduc- 
tion of  the  sutures  from  within  outwards,  their  knots  falling 
within  the  lumen  of  the  gut.  The  first  stitch  may  be  left 
long,  clamped  and  held  taut,  the  assistant  transferring  his 
forceps  to  the  points  on  the  circumferences  of  the  mouths  of 
the  gut  segments  opposite  to  the  mesentery,  where  the 
second  anchor  suture  is  passed.  Accurately  corresponding 
points  on  the  sides  are  lifted  up  in  turn,  everted  and  coapted. 
The  edges  of  intestine  are  to  be  turned  in  again  as  the 
sutures  are  tied  and  cut  short. 


'  Intestinal  Anastomosis.  21J^ 

This  method  of  introducing  the  deep  sutures  is  modified 
by  various  operators.  Thus  the  assistant  may  provide  two 
anchorage  sutures — for  the  mesenteric  edge  and  the  point 
opposite — to  be  left  long  and  held  taut,  while  a  continuous 
through  and  through  suture  is  passed  about  the  entire  cir- 
cumference, from  within  outward  from  the  mesenteric  to 
the  free  border,  and  from  without  inward  back  to  the  mesen- 
tery, where  it  is  tied  and  cut  short.  The  two  guy  sutures 
are  then  tied  while  the  edges  of  the  gut  are  being  pushed  in 
by  the  assistant. 

The  second  layer  of  stitches  (Lembert  sutures)  are  of  fine 
silk  on  small  straight  or  curved  needles.  To  prevent  snarl- 
ing, each  thread  should  be  of  moderate  length — not  longer 
than  for  two  sutures,  and  the  assistant  must  keep  the  strands 
separated  as  they  are  introduced.  As  they  are  being  tied, 
usually  in  batches  of  five  or  six,  the  serous  surfaces  are  to  be 
gently  adapted  with  forceps.  These  sutures  are  to__be  cut 
short.  The  intestinal  clamps  or  gauze  constrictors  are  then 
withdrawn.  After  the  surgeon  has  satisfied  himself  that  the 
intestine  is  everywhere  properly  closed,  the  assistant  lightly 
sponges  off  the  parts,  again  removes  the  underlying  soiled 
gauze  and,  cleansing  his  hands,  places  fresh  towels  under  the 
intestine,  which  is  now  spread  out  to  expose  the  mesentery. 
Continuous  or  interrupted  sutures  of  No.  2  catgut  on  half 
curved  needles  are  handed  for  the  coaptation  of  the  cut  mes- 
enteric edges,  the  assistant  keeping  the  tissue  spread  out  lest 
no  portion,  curled  up,  be  left  unsewed.  During  all  these 
manipulations,  if  the  intestines  are  much  exposed,  hot  towels 
should  be  replaced  as  soon  as  they  cool.  The  enterorrhaphy 
completed,  the  pads  and  towels  are  removed  and  the  abdom- 
inal walls  lifted  up  so  that  the  gut  may  Le  dropped  into  place, 
the  assistant  (and  nurse)  making  sure  that  no  sponge  or 
compress  is  left  within  the  abdominal  cavity. 

(2)  By  Maunsell's  Operation.  The  bowel  segments  are 
held  end  to  end  while  the  operator  inserts  a  long  temporary 
suture  through  all  the  coats  of  each  at  the  mesenteric  border, 
and  another  at  the  points  directly  opposite.  The  needles  are 
left  attached  to  these  sutures.     The  assistant  then  holds  the 


214  The  Surgical  Assistant. 

convex  border  of  the  proximal  segment  near  the  end  while 
the  surgeon  makes  a  slit  in  its  long  axis  with  scalpel  and 
scissors,  bleeding  points  being  compressed  with  hemostats. 
When  he  then  passes  the  two  temporary  sutures  into  the 
lumen  of  this  segment  and  out  through  the  slit,  the  assistant 
aids,  by  gentle  manipulation,  in  effecting  the  invagination 
that  results  and  in  the  extrusion  of  the  ends  of  gut,  one 
within  the  other,  through  the  lateral  opening.  He  then 
seizes,  the  two  long  sutures  and  draws  them  apart,  while  the 
operator  passes  sutures  of  silk  or  horsehair,  on  straight  cam- 
bric needles,  one  by  one  through  all  the  coats  of  the  bowel 
from  one  side  to  the  other.  These  sutures  are  picked  up 
within  the  lumen  of  the  gut,  cut  here,  and  the  two  ends  tied 
on  each  side.  Enough  of  these  interrupted  sutures  are  to 
be  provided  to  unite  the  ends  closely  throughout  their  cir- 
cumference. The  temporary  sutures  are  now  removed  and 
the  invagination  is  gently  reduced.  Lembert  sutures  are 
then  provided  for  sewing  the  lateral  slit  and  also  to  close 
any  gaping  spot  in  the  line  of  anastomosis.  After  changing 
the  towels  catgut  sutures  are  handed  for  the  mesentery. 

(3)  Lateral  Anastomosis.  The  assistant  thrusts  the 
edges  of  the  bowel  segments  into  their  respective  lumina  one 
at  a  time,  while  the  operator  closes  the  ends  with  Lembert 
sutures  of  rather  fine  silk.  The  selected  portions  of  gut  are 
held  together  side  by  side  while  Halsted  (square)  sutures 
or  one  or  two  rows  of  Lembert  sutures  are  inserted  to  unite 
them  near  the  mesenteric  border.  Scalpel  and  scissors  are 
then  handed  to  make  an  opening  in  each  segment  to  one  side 
of  the  suture  line,  the  assistant  compressing  bleeding  points 
with  hemostats.  A  long  (continuous)  suture  of  silk  is  then 
to  be  provided  for  "  whipping  over "  the  cut  edges  and 
uniting  the  two  adjacent  margins.  Silk  sutures  are  then 
needed  for  the  serous  surfaces  to  continue  around  the  open- 
ing the  line  of  Lembert  or  Halsted  stitches  first  introduced. 
Catgut  sutures  follow  for  the  mesentery. 

(4)  By  the  McGrazv  Rubber  Ligature.  The  surfaces  of 
gut  or,  in  gastro-enterostomy,  of  stomach  and  gut,  are  held 
evenly  in  apposition  while  a  row  of  Lembert  sutures  is  intro- 


Intestinal  Anastomosis,  215 

duced.  The  rubber  ligature  is  then  passed.  The  assistant 
should  select  a  firm  round  strand  of  rubber,  not  less  than  2 
mm.  in  diameter,  and  of  good  quality,  and  mount  this  in  a 
straight  round  or  Hagedorn  needle.  The  needle  having  been 
passed  into  and  partly  out  of  one  intestinal  segment,  the 
rubber  is  put  upon  the  stretch  while  it  is  rapidly  pulled 
through,  the  intestine  being  meanwhile  properly  steadied. 
The  rubber  is  to  be  again  stretched  while  it  is  passed  through 
the  other  segment.  While  the  operator  holds  it  drawn 
tightly  in  a  single  knot,  the  assistant  secures  the  latter  by 
tying  a  stout  strand  of  silk  firmly  about  it.  Silk  and  rubber 
are  then  cut  short  and  sutures  are  handed  with  which  to  con- 
tinue around  the  ligature  the  line  of  Lembert  stitches  first 

formed. 

(5)  By  the  Murphy  Button.    This  instrument  (appendix, 

fig.  48)  consists  of  a  "  male  "  and  a  "  female  "  half.  The 
former  bears  a  spring  flange  and,  projecting  from  its  stem, 
two  spring  metal  points  which  act  as  a  male  thread  when  in 
the  female  stem.  The  two  halves  may  be  united  by  pushing 
the  male  into  the  female  segment,  but  can  be  separated  only 
by  unscrewing  them  from  right  to  left.  Before  the  operation 
is  begun,  the  assistant  should  thus  separate  the  halves  of  the 
button  or  buttons  provided,  fastening  an  artery  forceps 
firmly  on  each  stem  to  serve  as  a  handle  for  it. 

By  means  of  thumb  forceps,  the  assistant  lifts  up  one  end 
of  the  intestine  with  the  operator,  while  the  latter  introduces, 
usually  with  a  cambric  or  straight  Hagedorn  needle,  a 
"  purse-string  "  or  "  puckering  "  suture  of  medium-sized 
silk,  the  ends  of  which  are  not  to  be  tied  nor  cut.  This 
procedure  is  repeated  on  the  other  segment. 

One  end  of  a  button  of  appropriate  size  is  then  handed  to 
the  operator,  by  means  of  the  attached  artery  forceps,  in  the 
manner  and  direction  shown  in  figure  77.  While  the  sur- 
geon is  introducing  the  button-half  into  one  end  of  the  gut, 
the  assistant  helps  him  in  holding  the  latter  open  with  thumb 
forceps.  He  then  takes  the  artery  forceps  from  the  operator, 
and  holding  it  vertically,  maintains  the  button-half  in  posi- 
tion (i.  e.,  with  its  stem  just  projecting  from  the  mouth  of 


216 


The  Surgical  Assistant. 


the  intestine),  while  the  purse-string  suture  is  tied  down 
upon  the  stem  and  cut  short.  An  assistant  then  holds  this 
end  of  the  gut,  in  such  a  manner  that  the  button  shall  not 
drop  into  it,  viz.,  by  gentle  traction  on  the  attached  artery 
clamp  or  by  slightly  compressing  the  intestine  just  beyond 


Fig.  77.     Manner  of  handing  half  of  Mnrphy  button.    Note  gauze  strips 
about  intestinal  segments  and  manner  of  holding  gut  for  reception  of  button. 


the  button.  The  same  manipulations  are  then  repeated  on 
the  other  segment  of  gut  with  the  opposite  half  of  the  button. 
The  assistant  removes  the  artery  clamps  when  the  operator 
lifts  up  both  ends  of  the  gut  to  unite  them.  The  parts  are 
then  gently  sponged  off.  Reinforcing  (Lembert)  sutures 
may  be  called  for.  Sutures  are  next  needed  for  the  mesen- 
tery. 

The  technics  of  assistance  in  the  introduction  of  the 
Murphy  button  for  lateral  anastomosis,  cholecystenteros- 
tomy  and  gastro-enterostomy  are  quite  similar  to  those  just 
described.  For  the  last  named  operation  it  is  well  to  pre- 
pare, if  possible,  a  button  with  one  small  and  one  large  end. 
(Weir's  modification).      The  large  end  is  to  be  handed  for 


Intestinal  Anastomosis.  217 

the  jejunum,  so  that  when  necrosis  has  taken  place  the  button 
will  fall  into  the  intestine  rather  than  into  the  stomach. 

(6)  By  Senn's  bone  plates,  Robson's  bobbin,  Laplace 
forceps  or  other  mechanical  device.  For  the  technics  of 
employing  these,  the  reader  is  referred  to  works  on  oper- 
ative surgery. 


CHAPTER  XVIIL 
ABDOMINAL  OPERATIONS.— Continued. 

OPERATIONS  UPON  THE    FEMALE    PELVIC  ORGANS  BY 
THE  ABDOMINAL  ROUTE. 

OVARIOTOMY  ;    SALPINGECTOMY. 

For  the  removal  of  an  ovarian  cyst  the  assistant  should 
prepare,  in  addition  to  the  other  instruments,  straight  and 
curved  clamps,  cyst  forceps  and  volsella,  aneurism  needles 
(right-  and  left-handed),  large  curved  trocar  and  canula 
(appendix,  fig.  9),  sponge  handles  and  a  Paquelin  cautery. 
Stout  silk  or  catgut  will  be  needed  for  the  pedicle  and  fine 
silk  sutures  may  be  required  for  sewing  intestinal  surfaces 
torn  by  the  separation  of  adhesions.  For  such  of  the  latter 
as  are  vascular.  No.  2  catgut  ligatures  will  be  needed. 
Packings,  pads,  hot  towels,  mounted  sponges  and  pus  basins 
should  be  at  hand. 

After  the  abdominal  wall  has  been  divided,  the  wound 
should  be  held  widely  open  with  retractors  while  the  opera- 
tor studies  the  size,  relations  and  character  of  the  tumor. 
Protruding  intestine  should  be  restrained  by  means  of  gauze 
compresses,  or,  if  necessary,  the  patient  may  be  lifted  at 
once  into  the  Trendelenburg  position.  If  the  cyst  is  not 
sufficiently  small  and  sufficiently  free  of  adhesions  to  deliver 
it  entirely  from  the  abdominal  cavity,  packings  are  inserted 
all  about  the  wound,  through  which  the  surface  of  the  tumor 
is  made  to  present.  The  trocar  (or,  lacking  this,  a  scalpel) 
is  then  handed  for  tapping  the  cyst^ — in  one  place  if  mono- 
locular,  in  several  places  if  multilocular.  As  the  puncture  is 
being  made,  and  while  drainage  is  taking  place,  the  assistant 
should  press  his  hands  firmly  on  each  side  of  the  abdomen, 

318 


Ovariotomy.  219 

both  to  facilitate  the  escape  of  the  fluid  and  to  prevent  its 
leakage  into  the  abdominal  cavity.  A  basin  or  bucket  should 
be  arranged  to  receive  the  cyst  contents. 

A  clamp  is  now  handed  for  closing  the  puncture  wound, 
and  volsella  for  lifting  the  cyst  wall  out  of  the  abdomen, 
retractors  being  inserted  again  to  facilitate  the  exposure  of 
adherent  bands.  For  the  division  of  these  the  operator  may 
need  blunt  scissors,  curved  on  the  flat;  the  assistant  helps 
by  clamping  all  vascular  adhesions  before  they  are  cut,  and 
tying  them  afterwards,  by  carefully  sponging  away  any  es- 
caping blood  or  cyst  fluid,  and  by  protecting  surrounding 
viscera  with  fingers  or  compresses.  For  the  pedicle  the  as- 
sistant now  provides  a  clamp  and  a  stout  ligature.  If  the 
pedicle  is  not  very  thick,  the  ligature  may  be  simply  tied 
about  it;  if  it  is  thick,  however,  the  ligature  should  be 
mounted  on  an  aneurism  needle  in  order  to  transfix  the  mass, 
which  is  then  ligated  by  one  of  the  methods  previously  de- 
scribed. Amputation  is  then  performed  with  scalpel  or  cau- 
tery, and  the  ligature  ends  are  cut  off.  When  the  stump  has 
been  returned  to  the  abdominal  cavity,  the  assistant  should 
expose  with  retractors  the  opposite  tube  and  ovary  for  in- 
spection. If  the  other  ovary  contains  small  cysts,  the  sur- 
geon may  desire  to  puncture  them  with  a  cautery  point. 

For  an  intraligamentoiLS  cyst  scissors  or  scalpel  will  be 
required  to  split  the  peritoneal  covering.  If  a  pedicle  exist, 
a  stout  ligature  is  required.  Bleeding  vessels  need  also  to 
be  tied.  A  suture  is  provided  for  reuniting  the  two  layers 
of  the  broad  ligament,  with  or  without  drainage. 

An  ovarian  abscess  or  pyosalpinx  requires  of  the  assistant 
the  same  technics  in  its  removal  as  above  described.  He 
should  observe  especial  care,  however,  not  to  rupture  the 
sac,  and  to  prevent  soiling  of  the  operating  field  by  any  pus 
that  may  escape.  Towels  and  compresses  should  therefore 
be  provided  to  cover  the  intestines,  even  though  the  Trendel- 
enburg position  is  employed,  and  a  few  sponges  on  handles 
should  be  kept  within  easy  reach  upon  the  patient's  abdomen, 
throughout  the  operation.  Gauze  and  tube  drains  should  be 
prepared. 


S^O  The  Surgical  AssisxANf, 

Ectopic  Gestation.  Hot  salt  solution  in  pitchers,  several 
mounted  sponges,  a  few  clamps,  stout  mounted  ligatures, 
and  numerous  packings,  should  be  in  readiness.  If  the 
patient  is  in  shock  from  the  loss  of  mvich  blood,  preparations 
ought  also  to  be  made  for  intravenous  infusion. 

Escaped  or  escaping  blood  must  be  quickly  sponged  from 
the  pelvis,  and  clamps  should  be  within  the  operator's  reach 
to  seize  any  large  vessel  that  may  be  bleeding.  The  technics, 
in  general,  are  as  for  simple  ovariotomy — separation  of  ad- 
hesions, clamping,  ligating,  ablating.  One  clamp  alone  may 
suffice,  but  often  the  operator  will  require  two — one  at  the 
uterine  end  of  the  tube  and  one  to  secure  the  ovarian  artery 
at  the  edge  of  the  broad  ligament.  Drainage  through  the 
vagina  may  be  desired,  especially  where  there  is  a  large,  old 
collection  of  blood  in  the  pelvis  (hematocele).  To  provide 
this,  a  pair  of  long-handled,  sharp-pointed  scissors,  curved 
on  the  flat,  is  required.  The  assistant  should  protect  the 
bladder  and  uterus  from  injury  while  the  incision  is  being 
made  in  the  vaginal  vault.  Through  this  opening  a  long 
dressing  forceps  is  thrust  from  below  to  seize  and  draw 
down  the  drainage  tube,  or  this  forceps  may  be  inserted  first 
and  the  incision  made  over  the  tips  of  its  blades,  thrust  into 
the  posterior  vaginal  fornix. 

In  a  case  of  advanced  ectopic  pregnancy,  a  suture  will  be 
needed  to  attach  the  cut  edge  of  the  gestation  sac  to  the 
edges  of  the  incision.  For  the  umbilical  cord,  if  the  fetus 
is  still  alive,  are  required  two  clamps  and  a  ligature.  Long, 
wide  gauze  packings  will  be  needed  to  fill  the  wound  from 
the  bottom. 

HYSTERECTOMY. 

The  instruments  to  be  laid  out  are :  those  needed  for  the 
dissection  and  retraction  of  the  abdominal  wall ;  several  (six, 
at  least)  long,  straight  and  curved  clamps;  aneurism  needles 
(right-  and  left-handed)  ;  sponge  handles;  a  bladder  sound; 
long-bladed  dressing  forceps ;  and,  if  the  operation  is  for  a 
large  tumor  of  the  uterus,  strong  volsella.    To  these  may  be 


Abdominal  Hysterectomy,  221 

added  a  Paquelin  cautery  and  an  aspirating  syringe.  The 
following  ligatures  and  sutures  should  be  prepared  :  those  for 
the  abdominal  wall  itself;  fine  silk  sutures  for  torn  intestinal 
surfaces ;  number  2  catgut  ligatures  for  vascular  adhesions ; 
six  stout  catgut  (No.  4)  or  silk  ligatures  for  the  broad  liga- 
ments; two  long  medium-fine  catgut  (No.  i)  sutures  on 
half-curved  needles,  for  uniting  the  layers  of  the  broad  liga- 
ments and  sewing  the  peritoneal  flaps  over  the  cervical 
stump  or  the  roof  of  the  vagina.  Several  large  packings 
should  also  be  ready,  as  well  as  pads,  hot  towels,  specimen 
dishes,  etc. 

Assistance  is  rendered  in  separating  adhesions  and  in 
packing  away  the  intestines  and  omentum  in  the  manner  de- 
scribed under  ovariotomy.  The  uterus  and  its  adnexa  thus 
freed,  and  the  patient's  pelvis  raised  in  the  Trendelenburg 
position,  the  organ  is  drawm  to  one  side,  usually  toward  the 
operator,  either  by  the  surgeon  or  by  the  assistant.  An  ap- 
propriate aneurism  needle  bearing  a  stout  ligature  is  then 
handed  to  secure  the  ovarian  artery  and  upper  portion  of  the 
exposed  broad  ligament.  When  the  point  of  the  needle  has 
been  thrust  through  the  ligament — beneath  the  Fallopian 
tube  if  the  ovary  is  to  be  saved,  beyond  the  tube  if  the  ovary 
is  to  be  sacrificed — the  assistant  grasps  the  ligature  with 
mouse-tooth  forceps  and  draws  one  end  of  it  completely 
through.  (While  this  ligature  is  being  tied  the  aneurism 
needle  should  be  re-threaded.)  A  straight  clamp  is  next 
required,  to  be  applied  distal  to  the  ligature,  and  then  scissors 
for  dividing  the  broad  ligament  between  ligature  and  clamp. 
Aneurism  needle,  clamp  and  scissors  are  passed  in  the  same 
order  a  second,  and  if  necessary  a  third,  time,  to  secure  the 
remainder  of  the  ligament.  The  uterus  is  then  drawn 
toward  the  side  thus  treated,  and  the  opposite  broad  ligament 
is  similarly  attacked.  An  assistant  may  then  insert  a  sound 
into  the  bladder  (from  below)  if  the  operator  signifies  that 
he  requires  this  in  order  to  assure  himself  of  the  upper  limit 
of  this  organ.  Blunt  scissors,  curved  on  the  flat,  are  then 
passed  to  the  surgeon  for  dividing  the  peritoneum  across  the 
anterior  surface  of  the  uterus,  and  for  stripping  down  peri- 


222  The  Surgical  Assistant. 

toneum  and  bladder.  When  the  location  of  the  uterine  ar- 
teries is  determined,  mounted  ligatures  are  passed  to  secure 
each  of  them  in  two  places,  between  which  they  will  be  di- 
vided. 

If  supravaginal  hysterectomy  is  to  be  performed  there  is 
now  needed  a  scalpel,  with  which  to  amputate  through  the 
upper  portion  of  the  cervix.  Upon  the  stump  the  assistant 
holds  a  sponge  temporarily.  A  basin  is  held  to  receive  the 
uterus  and  the  scalpel, — the  latter  being  discarded  because 
it  may  have  been  contaminated  by  organisn.  ;  in  the  uterine 
canal.  A  cautery  may  next  be  desired  to  sterilize,  by  sear- 
ing, the  upper  surface  and  the  canal  of  the  cervical  stump. 
Some  operators  remove  a  wedge  from  the  upper  aspect  of 
the  stump  in  order  to  close  it;  for  this  purpose  another 
scalpel  or  a  stout  pair  of  sharp-pointed,  curved  scissors  will 
be  required.  A  pair  of  mouse-tooth  forceps  and  a  running 
suture  of  catgut  on  a  half-curved  needle,  are  next  handed  to 
the  operator  for  uniting  the  two  layers  of  the  broad  liga- 
ment on  each  side  of  the  cervix  and  for  sewing  the  perito- 
neal flaps  over  the  stump. 

Where  complete  hysterectomy  is  to  be  performed,  after 
the  bladder  has  been  stripped  off  and  the  uterine  arteries  se- 
cured, an  assistant  thrusts  a  pair  of  dressing  forceps  into  the 
vagina  in  such  a  manner  that  the  operator  can  incise  through 
the  posterior  fornix  along  the  line  marked  by  the  opened 
blades  of  the  forceps.  Small  clamps  should  be  ready  for 
bleeding  vessels  on  each  side  of  the  cut  section  of  the  vagina. 
A  strip  of  gauze  is  prepared  for  insertion  into  the  vagina 
after  the  cervix  has  been  completely  separated,  and  this 
gauze  is  drawn  upon  by  an  assistant  from  below  until  its 
upper  edge  is  flush  with  the  open  vaginal  vault.  The  run- 
ning suture  for  the  broad  ligament  is  then  handed  as  after 
the  supravaginal  operation. 

Operator  and  assistant  now  sponge  out  the  pelvis  and  re- 
move pads,  packings  and  retractors.  The  patient  is  lowered 
into  the  horizontal  position,  and  sutures  are  handed  with 
which  to  close  the  abdominal  wound. 


Cesarean  Section.  223 


CESAREAN    SECTION. 


The  usual  instruments  of  dissection  are  all  that  are  ordi- 
narily needed,  but  it  is  well  to  provide  clamps  and  aneurism 
needles  also,  for  it  may  be  necessary  or  desirable  to  perform 
hysterectomy  or  to  sterilize  the  patient  by  resection  of  the 
Fallopian  tubes.  A  stout  rubber  tube,  a  yard  long  (Es- 
march  constrictor)  is  also  to  be  ready,  although  it  is  not  re- 
quired for  hemostasis  if  there  is  a  sufficient  number  of 
assistants  at  hand.  Several  sutures  of  stout  silk  in  half- 
curved  needles,  and  several  of  fine  silk  in  full-curved  needles, 
are  to  be  prepared.  There  should  be  ready  for  the  child  a 
blanket,  umbilical  tape,  "  mouth  wipes,"  and  tubs  of  hot  and 
cold  water  (although  these  latter  will  probably  not  be  needed 
after  a  delivery  by  abdominal  section). 

After  the  division  of  the  abdominal  wall  and  the  exposure 
of  the  uterus  the  rubber  constrictor  is  handed  to  the  operator 
if  he  requires  its  use.  As  it  is  slipped  over  the  fundus  and 
twisted  about  the  lower  zone  of  the  organ  the  assistant 
should  see  that  no  segment  of  intestine  is  included  in  its 
grasp.  The  assistant  now  places  a  hand  flat  upon  each 
side  of  the  abdominal  wall,  pressing  firmly  downwards  and 
backwards  against  the  womb  both  to  cause  gaping  of  the 
wound  against  the  surface  of  uterus,  and  to  prevent  the 
escape  of  blood  and  liquor  amnii  into  the  peritoneal 
cavity. 

Clamps  and  scissors  should  be  at  hand  for  appplication 
to  the  umbilical  cord  as  soon  as  the  uterus  has  been  cut 
through  and  the  child  extracted.  The  infant  is  received  in 
a  blanket  by  a  nurse  or  other  assistant  who  should  be  ready 
to  give  it  whatever  immediate  attention  it  may  require. 
The  usually  moderate  escape  of  blood  from  the  uterus  may 
be  sponged  away,  but  the  assistant  who  is  compressing  the 
abdominal  wall  should  not  remove  his  hands  for  this  pur- 
f>ose ;  rather  he  should  increase  his  pressure  upon  the  organ. 
If  the  placenta  is  lying  in  the  line  of  uterine  cection  the  hem- 
orrhage will  be  profuse,  however,  and  then  the  assistant  may 
transfer  his  grasp  to  the  lower  part  of  the  womb  where  he 


224  The  Surgical  Assistant. 

is  to  compress  the  broad  ligaments.     If  the  rubber  ligature 
has  been  used  this  may,  instead,  be  simply  tightened. 

A  basin  is  held  to  receive  the  placenta  and  membranes. 
When  the  uterus  has  been  emptied  and  delivered  through 
the  wound  the  assistant  should  spread  compresses  beneath 
the  organ.  The  surface  of  the  womb  is  then  sponged  clean 
and  fresh  towels  are  rapidly  spread  about  it,  in  preparation 
for  the  insertion  of  the  sutures.  The  stout  sutures  are 
handed  first  in  rapid  succession.  They  are  to  be  clamped 
one  by  one  as  they  are  passed,  being  tied  and  cut  short  after 
all  are  in  place.  The  fine  silk  sutures  for  the  serous  surface 
are  then  provided,  the  assistant  inverting  and  adapting  the 
peritoneal  margins  as  the  stitches  are  tied.  After  this  the 
compresses  are  removed  and  the  abdominal  wound  is  pre- 
pared for  closure. 


CHAPTER  XIX. 

ALEXANDER'S  OPERATION.     HERNIOTOMY. 

Alexander's  operation  of  shortening  the  round 
ligaments  of  the  uterus. 

The  assistant  stands  upon  the  patient's  left  side,  opposite 
to  the  operator.  A  sharp  scalpel  is  handed,  and  artery  for- 
ceps are  placed  near  by.  The  left  side  is  first  attacked, 
usually.  If  the  assistant  needs  to  help  in  steadying  the  skin 
for  the  incision,  this  must  be  done  in  a  manner  not  to  displace 
the  latter  from  the  line  of  the  inguinal  ring  beneath.  Bleed- 
ing vessels  in  the  skin  having  been  clamped,  a  sharp  re- 
tractor is  inserted  into  each  side  of  the  wound.  By  means 
of  mouse-tooth  forceps  the  assistant  picks  up  the  fascia  and 
fat,  with  the  operator.  When  the  external  inguinal  ring 
has  been  exposed  and  the  ligament  drawn  out  the  latter  is 
clamped  close  to  the  opening,  and  a  sterile  compress  is  placed 
over  the  wound.  The  right  side  is  then  dissected  in  the 
same  way.  Fresh  towels  are  now  spread  and  short  sutures 
(of  chromicized  catgut  or  silk),  in  half-curved  needles  are 
handed.  These  are  for  suturing  the  ligaments  in  the  in- 
guinal ring  on  the  right  side.  The  ligament  is  to  be  drawn 
well  down  by  the  assistant  while  these  interrupted  sutures 
are  being  inserted.  During  this  manipulation  the  assistant 
should  guard  from  inclusion  in  the  stitches  the  inguinal 
branch  of  the  ilio-inguinal  nerve,  which  the  surgeon  has 
separated  from  the  ligament.  A  clamp  may  be  applied  to 
each  stitch  as  it  is  inserted  until  all  are  in  place.  With  for- 
ceps the  assistant  brings  the  edges  of  the  ring  over  the  liga- 
ment while  the  stitches  are  being  fastened.  The  deep  su- 
tures all  tied,  a  ligature  is  provided  for  the  projecting  end 

335 


226  The  Surgical  Assistant. 

of  the  ligament  in  order  to  secure  the  bloodvessels  that 
accompany  it.  A  pair  of  scissors  or  a  scalpel  is  next  passed 
to  remove  the  redundant  end  of  the  ligament;  then  silk  or 
catgut  stitches  for  the  skin.  The  assistant  covers  the  sutured 
wound  on  the  right  side  with  a  compress,  and  again  inserts 
retractors  on  the  left  side — where  the  sutures  are  now  intro- 
duced. The  dressings  should  be  ample  and  may  advisedly 
be  covered  with  gutta-percha  tissue  to  prevent  soiling  from 
below.  It  is  secured  with  a  double  spica  bandage 
(page  233). 

VENTRAL    HERNIOTOMY. 

Preparations  are  made  as  for  any  laparotomy.  Clamps 
and  several  stout  (No.  4)  catgut  ligatures  should  be  pro- 
vided for  ablating  omentum,  and  numerous  No.  2  ligatures 
will  probably  be  needed  for  adhesions.  Chromicized  cat- 
gut (preferably  "40  day"),  kangaroo  tendon,  silkworm- 
gut,  silver  wire  or  silk  will  be  used  for  the  deep  sutures,  ac- 
cording to  the  surgeon's  technic.  Silver  filigree  (wire 
mesh)  is  sometimes  employed,  to  be  held  by  a  few  silver 
wire  stitches  in  a  gap  that  cannot  be  closed  completely  or 
with  sufficient  support,  by  autoplastic  methods. 

The  anesthetist  should  keep  the  patient  well  "  under " 
throughout  the  operation  in  order  to  prevent  protrusion  of 
intestine — for  the  protection  of  which,  however,  gauze  pack- 
ings and  pads  should  be  in  readiness.  The  wound  assistant 
helps  in  the  separation  of  adhesions,  usually  present  between 
omentum  and  sac,  [in  the  ablation  of  omentum  (page  140)], 
and  in  the  adaptation  of  the  aponeurotic  flaps  according  to 
whatever  method  the  operator  indicates.  If  the  hernia  is 
a  post-operative  condition  the  assistant  aids  in  exposing  the 
retracted  edges  of  the  individual  aponeuroses  and  muscles 
and  in  their  approximation,  in  regular  order,  by  sutures 
(page  191). 

Over  the  dressing  should  be  tightly  drawn  several  straps 
of  adhesive  plaster  in  order  to  take  as  much  strain  as  pos- 
sible from  the  sutures. 


Herniotomy.  227 


INGUINAL    HERNIOTOMY. 


Bassini  Operation.  In  addition  to  the  other  instruments 
of  dissection  there  should  be  provided  a  pair  or  more  of 
four-pronged  sharp  retractors,  one  or  two  blunt  hooks,  a  few 
clamps,  and  about  a  dozen  artery  forceps.  Several  deep 
sutures  of  silk  (as  used  by  Bassini  himself),  forty  day  chro- 
micized  catgut,  kangaroo  tendon  or  horsehair — according  to 
the  surgeon's  technic, — should  be  mounted  in  medium-sized, 
sharp,  half-curved  needles.  In  a  fair-sized  full-curved 
needle  is  to  be  mounted  a  suture  of  No.  2  catgut  for  the  neck 
of  the  sac.  Catgut  or  silk  sutures  in  full-curved  needles  are 
to  be  ready  for  the  skin.  If  a  strangulated  hernia  is  to  be 
dealt  with  preparations  should  be  made  for  intestinal  resec- 
tion, as  previously  described. 

The  scrotum  or  vulva  and  the  upper  part  of  the  anterior 
aspect  of  the  thigh,  as  well  as  the  pubic  and  lower  abdominal 
regions,  are  to  be  carefully  shaved.  The  genitals  and  a 
large  area  of  skin  in  the  neighborhood  of  the  groin  should 
be  thoroughly  scrubbed  with  soap  and  water  (under  anes- 
thesia) and  carefully  disinfected.  Before  the  operation  is 
begun  the  penis  should  be  enveloped  in  a  few  turns  of  a 
sterile  bandage  or  gauze  strip,  secured,  without  undue  con- 
striction, by  means  of  an  ordinary  rubber  band,  sterilized  by 
boiling.  If  the  penis,  although  previously  cleansed,  is 
touched  by  the  assistant's  fingers  while  he  is  thus  bandag- 
ing it  he  should  disinfect  his  hands  again  before  handling 
any  instrument  or  towel — for  strict  asepsis  is  important  to 
the  success  of  the  operation.  To  this  end,  also,  it  is  very  de- 
sirable that  rubber  gloves,  caps  and  mouth  covers  should  be- 
worn. 

The  assistant  aids  in  holding  the  skin  taut  for  the  pri- 
mary incision  and  then  in  securing  all  divided  branches  of 
the  external  pudic  arteries — for  the  wound  must  be  kept 
as  free  from  blood  as  possible.  Retractors  are  next  to  be 
inserted  in  the  skin  to  expose  the  cremaster  and  external 
oblique.  Retraction  of  this  muscular  layer  after  its  division 
then  lays  bare  the  cord.     If  the  sac  is  not  at  once  visible, 


228 


The  Surgical  Assistant. 


nor  found  by  slight  teasing  of  the  cord  structures  v/ith  a  pair 
of  anatomical  forceps,  the  operator  will  probably  desire  that 
the  anesthetic  be  withdrawn  temporarily  in  order  that  the 
patient  may  strain  the  sac  into  view.  When  it  has  been 
found,  it  is  lifted  up  by  the  surgeon  and  the  assistant  by  two 
mouse-tooth  forceps,  in  order  that  it  may  be  opened  between 
them  (figure  78).  The  assistant  then  clamps  two  or  three 
artery  forceps  on  the  cut  edge  of  the  sac  while  the  operator 


Fig.  78.    Retraction  of  divided  external  oblique,  exposing  the  sac,  which  is 
being  opened  between  two  mouse-tooth  forceps. 


explores  its  interior.  If  the  hernia  is  of  the  congenital 
variety  clamps  are  also  affixed  temporarily  to  the  edge  of 
the  lower  end  of  the  sac,  after  it  is  divided. 

The  contents  of  the  hernia  determine  the  next  step.  Thus, 
if  omentum  presents,  catgut  ligatures  are  needed  to  secure 
its  bloodvessels  preparatory  to  its  amputation;  if  strangu- 


Herniotomv.  229 

latecl  intestine  is  found,  hot  towels  may  be  called  for  in  order 
to  test  its  viability ;  etc. 

When  the  hernial  contents  have  been  dealt  with  a  strip 
of  gauze  may  be  needed  to  insert  into  the  neck  of  the  sac  to 
prevent  protrusion  of  viscera,  while  the  sac  and  cord  are  be- 
ing separated.  In  aiding  in  this  latter  manipulation  the  as- 
sistant must  use  his  anatomical  forceps  gently,  for  the  pamp- 


<^^- 


Fig.  79.    Separation  of  sac  from  cord.    Note  bandage  around  penis,  artery 
clamp  attached  to  cut  edge  of  sac,  blunt  hook  lifting  up  cord. 

inniform  plexus  is  easily  bruised  and  made  to  bleed.  He 
should  also  guard  the  vas  deferens  against  any  injury  by 
the  surgeon's  knife  or  scissors.  The  sac  having  been  sepa- 
rated the  assistant  holds  aside  the  cord  structures  by  means 
of  a  blunt  hook  or  fillet  of  gauze — again  exercising  gentle- 
ness in  order  to  avoid  pulling  the  testicle  out  of  the  scrotum 
or  producing  a  hematoma  in  the  cord. 


230 


The  Surgical  Assistant. 


The  gauze  strip  now  removed  from  the  canal,  the  purse- 
string  catgut  suture  is  handed  for  insertion  into  the  neck  of 
the  sac.  While  this  is  being  introduced  the  assistant  lifts 
up  on  the  forceps  attached  to  the  sac,  and  as  the  purse-string 
is  being  drawn  together  he  inserts  a  slender  instrument, 
e.  g.,  a  sponge  handle,  into  the  canal  to  prevent  any  protrud- 
ing intestine  from  being  caught  in  the  ligature.  After  the 
first  knot  the  sac  is  still  held  up  while  the  ligature  is  passed 
once  more  about  the  neck ;  then  scissors  are  handed  to  ab- 


FlG.  80.  Iirtroduction  of  deep  sutures.  Sac  has  been  tied  and  amputated. 
Cord  is  being  drawn  aside  with  ganze  fillet.  Sharp  retractors  expose  internal 
oblique  and  conjoined  tendon  above,  and  shining  inner  aspect  of  Poupart's 
ligament  below.  Through  these  the  needle  is  being  passed.  Artery  forceps 
clamp  the  sutures,  one  by  one,  until  all  are  to  be  tied. 


late  the  sac  and  the  catgut  ends.  If  a  congenital  hernia 
is  being  dealt  with  a  suture  of  No.  i  catgut  is  next  needed 
to  form,  by  means  of  a  purse-string,  a  tunica  vaginalis  testis 
of  the  scrotal  portion  of  the  peritoneal  pouch. 


Herniotomy. 


231 


The  cord  still  drawn  gently  to  one  side  (toward  the  um- 
bilicus), sharp  retractors  are  next  inserted  into  the  external 
oblique,  in  order  to  thoroughly  expose  the  internal  oblique 
and  conjoined  tendon  above,  and  into  the  aponeurotic  in- 
sertions in  Poupart's  ligament  in  a  manner  to  expose  the 
shining  inner  aspect  of  this  ligament  below — as  shown  in 
figure  80.  These  retractors  should  be  so  placed  that  they 
bring  the  upper  angle  of  the  wound  into  view — for  the  oper- 
ator may  desire  to  incise  the  deep  aponeurosis  and  trans- 


FlG.  81.    Second  suture  layer,  restoring  the  external  oblique.    Cord   has 
been  released  and  retractors  shifted  to  the  skin. 


plant  the  cord  to  a  new  site  of  exit,  or  to  insert  a  stitch  in 
the  internal  oblique  above  the  cord.  Care  should  be  exer- 
cised that  the  prongs  of  the  lower  retractor  do  not  pierce 
the  femoral  vessels  lying  just  beneath  Poupart's  ligament. 
The  (interrupted)  deep  sutures  are  then  handed.  As 
they  are  inserted  into  the  conjoined  tendon  above  and  the 


232 


The  Surgical  Assistant. 


ligament  below  they  are,  one  by  one,  "  cut  long  "  and  secured 
in  artery  forceps.  When  all  are  in  place  they  are  handed 
to  the  operator  again  in  regular  order,  for  tying;  and  after 
all  are  tied  they  are  cut  short.  The  wound  is  then  sponged 
out,  the  cord  released  and  the  retractors  removed  to  the 


FiS.  82.     Diagram  showing  turns  of  bandage   in  dressing  after   inguinal 
herniotomv. 


skin.  Next  are  handed  interrupted  or  running  sutures  with 
which  to  unite  the  edges  of  the  external  oblique  (figure  8i). 
After  this  the  wound  is  again  sponged  and  the  skin  sutures 
are  provided.  Before  these  are  introduced  the  operator  may 
want  a  running  suture  for  the  fascia. 

A  pad  of  gauze  is  to  be  held  over  the  groin,  while  the 
towels  are  being  removed  and  a  hip  rest  slipped  under  the 
lumbar  region.  While  gauze  pads  and  a  single  spica  band- 
age will  suffice,  it  is  better  to  apply  the  dressing'to  a  male 
patient  in  the  following  manner.  The  groin  is  evenly  filled 
with  gauze  pads  and  absorbent  cotton,  and  loose  gauze  is 
placed  over  the  scrotum,  which  is  to  be  held  up.    Over  the 


Herniotomy. 


233 


iliac  spines  a  little  absorbent  cotton  is  placed.  To  prevent 
soiling  of  the  dressing  a  sheet  of  gutta-percha,  perforated  for 
the  penis,  may  be  used  to  cover  it.  The  bandages,  six  inches 
wide,  are  applied  as  shown  in  figures  82  and  83.  A  few  cir- 
cular turns,  over  the  iliac  crests,  are  first  passed.  Then  the 
roller  is  brought  down  over  the  right  groin  and  the  scrotum, 
across  the  perineum,  behind  and  around  the  left  thigh  (in 
the  gluteo-femoral  line),  around  the  abdomen  again,  from 
the  patient's  left  to  right  in  front  and  from  his  right  to  left 
behind,  down  over  the  left  groin  and  the  scrotum,  across  the 
perineum  and  behind  the  right  thigh,  etc. — thus  forming 
a  double  spica,  or  figure-of-eight  bandage  crossing  the  per- 


FlG.  83.    Diagram  showing  perineal  turns  of  bandage  in  dressing  after 
inguinal  herniotomy. 


ineum  (in  front,  of  course,  of  the  anus).  A  few  turns  of 
a  starch  bandage  may  be  applied  over  the  gauze  bandage. 
For  female  patients  a  single  or  double  spica  should  be  so 
applied  that  the  vulva  is  left  free. 

The  technics  of  the  assistant  in  herniotomies  by  other 
methods  than  Bassini's,  need  no  separate  description.  Ref- 
erence to  a  work  on  operative  surgery  will  indicate  to  him 
the  modifications  he  need  make  of  the  above  details,  in  Hal- 
gted's,  McEwen's  and  other  operations, 


234  The  Surgical  Assistant. 


FEMORAL    HERNIOTOMY. 


The  assistant's  manipulations  here  are  also  but  an  adapta- 
tion of  those  described  for  inguinal  herniotomy.  A  catgut 
(purse-string)  suture  is  needed  for  the  sac;  and  silk  or 
chromicized  catgut  sutures  for  the  canal, — either  another 
purse-string,  or  two  or  more  interrupted  stitches,  as  used, 
for  example,  to  unite  Poupart's  ligament  and  the  pectineal 
fascia. 


CHAPTER  XX. 

OPERATIONS  UPON  THE  KIDNEY  AND  URETER. 

OPERATIONS  UPON  THE  KIDNEY. 
LUMBAR    ROUTE. 

The  patient  is  laid  upon  his  side,  the  affected  kidney  up- 
permost. Under  the  opposite  loin  is  placed  a  cylindrical 
or  triangular  cushion,  about  eight  inches  in  diameter.  Lack- 
ing either  of  these  an  ordinary  bed  pillow  may  be  rolled 
tightly  into  a  cylinder,  secured  with  a  bandage,  and  cov- 
ered with  rubber  sheeting  or  oilcloth.  The  patient's  lower 
arm  lies  under  the  chest,  the  forearm  being  free  ;•  but  the 
anesthetist  should  change  the  position  of  this  extremity  from 
time  to  time  to  avoid  pressure  paralysis.  The  other  arm 
is  held  across  the  chest  in  an  easy  position  by  pinning 
the  sleeve  to  the  shirt.  The  head  rests  on  a  pillow.  The 
chest  and  the  lower  extremities  should  be  covered  with 
blankets.  The  entire  abdomen  and  back  are  to  be  disin- 
fected. When  the  sterile  towels  are  spread  about  the  field 
of  operation  it  will  be  wise  to  pin  to  the  others  those  cover- 
ing the  belly  and  the  back,  lest  they  otherwise  fall.  It  should 
be  remembered  too,  that,  because  of  the  patient's  position, 
instruments  laid  upon  the  body  are  apt  to  fall,  and  they 
should  therefore  not  be  allowed  to  accumulate  there. 

The  instruments  required  for  nephrectomy  are :  those  ordi- 
narily needed  for  dissection,  a  ligature  carrier  or  aneurism 
needle,  two  or  more  clamps  (if  a  large  neoplasm  is  to  be 
dealt  with  several  clamps  should  be  provided  to  secure  ad- 
hesions), an  aspirating  syringe  with  a  long  needle  of  gener- 
ous calibre,  and  sponge  handles.  Since  rib  resection  is 
occasionally  necessary  it  is  well  to  provide  also  periosteal 

235 


236  The  Surgical  Assistant. 

elevator,  raspatory,  osteotome  and  bone  hook.  For  the 
pedicle  there  should  be  at  hand,  for  the  operator  to  select 
from,  ligatures — about  twelve  inches  long — of  solid  rubber, 
of  heavy  twisted  silk  and  of  stout  catgut  (No.  4  to  No.  6). 
Several  gauze  compresses  about  four  inches  wide  and  six- 
teen inches  long,  of  four  to  eight  thicknesses,  are  to  be  cut 
and  folded.  The  wound  sutures  to  be  prepared  are  usually 
of  stout  braided  silk,  or  one  or  two  strands  of  silkworm- 
gut,  in  heavy  full-curved  needles;  these  sutures  being  sup- 
plemented by  catgut  for  the  skin  and,  sometimes,  by  chromi- 
cized  catgut  for  the  muscles. 

For  nephrotomy  the  same  instruments  and  materials 
should  be  ready  as  for  nephrectomy,  since  the  necessity  for 
the  removal  of  the  kidney  may  develop  in  the  course  of  the 
operation.  In  addition,  spoon  forceps  are  desirable,  narrow 
gauze  drains  and  drainage  tubes.  These  last  (which  may 
even  be  called  for  after  nephrectomy  too)  should  be  of  red 
rubber,  preferably,  half  an  inch  in  diameter  and  about  eight 
inches  long.  Two  are  all  that  are  apt  to  be  required,  and 
ordinarily  they  need  not  be  fenestrated.  An  irrigator,  con- 
taining hot  salt-,  or  weak  sublimate-solution,  should  be 
at  hand.  To  re-unite  a  kidney  that  has  been  split  in  explora- 
tion or  for  the  removal  of  a  calculus,  sutures  are  required 
of  No.  3  catgut  in  long,  sharp,  full-curved  needles,  and  of 
No.  2  catgut  in  smaller  half-curved  needles. 

For  nephropexy  the  instruments  of  dissection  are  all  that 
are  needed,  the  sutures  to  be  prepared  depending  upon  the 
operator's  choice  of  technic. 

The  assistant  faces  the  patient's  abdomen,  standing,  if 
necessary,  on  a  foot-stool.  The  help  to  be  rendered  in  the 
division  of  the  lumbar  muscles  and  the  exposure  of  the  kid- 
ney bed  is  as  described  for  lumbar  colostomy. 

If  the  kidney  does  not  at  once  appear  satisfactorily  in  the 
wound  the  assistant  presses  the  fingers  of  one  hand  upwards 
and  into  the  abdomen  in  order  to  thrust  up  the  organ  and 
he  thus  holds  it  until  the  operator  has  it  securely  in  his  grasp. 

Nephrectomy.     Ligatures  may  be  required  for  bloodves- 


Operations  Upon  the  Kidney. 


237 


sels  at  the  poles  of  the  kidney  that  have  to  be  severed  in  the 
course  of  the  delivery  of  the  organ.  When  the  surgeon 
has  reached  the  pedicle,  the  assistant  should  have  a  clamp 
at  hand,  lest  a  rupture  of  the  renal  artery  or  vein  should  in- 
advertently take  place.  If  the  pedicle  is  to  be  ligated  en 
masse  with  a  rubber  strand  the  assistant  secures  this  ligature 
with  a  long  piece  of  heavy  silk,  knotted  tightly  around  the 
rubber  at  its  point  of  crossing.  The  silk  thread  is  left  long, 
the  rubber  cut  moderately  short.  Silk  or  catgut  ligatures 
to  be  tied  around  the  individual  vessels  should  be  in  ligature 
carriers.     They  are  usually  left  long  in  order  to  expose  the 


Fig.  84.    Assistant  pushing  up  the  kidney  by  pressure  on   the  abdomen. 
Note  the  cushion  under  the  lower  loin. 


pedicle  in  the  event  of  bleeding  after  the  kidney  is  removed. 
The  slipping  of  one  of  these  ligatures  is  an  accident  the  pos- 
sible occurrence  of  which  the  assistant  must  bear  in  mind. 
To  meet  such  a  condition  the  emergency  clamp  above  re- 
ferred to  should  be  kept  within  easy  reach  until  the  very  con- 
clusion of  the  operation.  In  some  cases  the  operator  will 
find  it  necessary  to  leave  one  or  more  clamps  on  the  pedicle 
instead  of,  or  in  addition  to,  the  ligatures.     In  that  event 


238  The  Surgical  Assistant. 

the  assistant  holds  the  instruments  Hghtly  in  a  vertical  posi- 
tion, carefully  avoiding  traction,  while  gauze  packings  are 
inserted  all  about  to  support  them.  A  large  ring  of  loose 
gauze  is  to  surround  the  handles  beyond  the  wound,  and  a 
firm  dressing  is  to  be  so  applied  that  they  cannot  move  about. 

Usually  a  single  drain  of  gauze,  sometimes  of  tubing,  is 
to  be  supplied,  the  greater  part  of  the  wound  being  closed 
with  the  sutures  above  mentioned.  If,  for  any  reason,  the 
wound  is  to  be  left  open,  several  gauze  packings  will  be 
needed,  with  or  without  a  "Mikulicz  bag"  (page  122). 
The  dressing  should  be  abundant  and  compressive. 

Nephrotomy.  Unless  the  condition  of  the  kidney  is  at 
once  evident  the  aspirating  needle  and  white  specimen  dish 
will  probably  be  wanted  as  soon  as  the  kidney  is  well  ex- 
posed. To  maintain  this  exposure  the  assistant  may  be 
obliged  to  continue  manual  pressure  upon  the  abdomen 
throughout  the  operation.  Sometimes,  however,  especially 
when  the  kidney  has  to  be  split  through  the  greater  part  of 
its  length,  he  may  be  required,  instead,  to  pass  the  thumb  and 
forefinger  of  each  hand  beneath  the  organ  to  compress  the 
renal  vessels, — this  to  prevent  suffusion  of  the  field  and  un- 
due loss  of  blood.  Similarly  the  operator  may  desire  a 
clamp  or  a  ligature  to  temporarily  constrict  the  vessels.  In 
such  cases  the  compression  is  to  be  maintained  until  the 
manipulations  of  the  kidney  are  concluded. 

All  stones  that  are  removed  should  be  received  in  a  dish. 
The  drainage  required  for  a  calculous  kidney  must  be  in- 
dicated to  the  assistant  by  the  general  condition  of  the  organ. 
If  the  wound  in  the  kidney  is  to  be  closed,  after  section  or 
resection,  there  are  handed  first  the  No.  2  deep  catgut  su- 
tures, in  half-curved  needles,  and  then  the  No.  3  sutures, 
in  heavier  full-curved  needles,  to  be  passed  through  the  kid- 
ney and  tied  over  its  convex  border.  The  first  set  of  stitches 
may  not  be  needed,  however.  If  a  uro-  or  pyo-nephrosis  is 
to  be  evacuated,  packings  should  be  handed  for  insertion 
about  the  kidney,  and  the  patient's  body  should  be  tilted 
somewhat  backwards.  A  pus  basin  is  to  be  held  beneath 
the  wound,  and  two  drainage  tubes  are  to  be  ready  for  in- 


Operations  Upon  the  Kidney.  239 

trodtiction.  Through  these  the  operator  may  wish  to  ir- 
rigate. Gauze  packings  will  be  needed  around  them  to 
partly  or  entirely  fill  the  wound,  as  the  surgeon  may  decide. 
Upon  the  surface  of  the  wound  an  abundance  of  loose  gauze 
is  to  be  placed,  and  over  this,  flat  compresses,  with  or  with- 
out a  covering  of  rubber  tissue,  and  a  firm  bandage. 

Nephropexy.  In  the  operation  of  Edebohls  according 
to  his  own  technic,  the  patient  is  placed  prone  upon  the 
cushion,  i.  e.,  in  the  position  of  ventral  decubitus.  For  the 
performance  of  the  operation  by  other  methods  the  lateral 
position  is  to  be  employed. 

The  assistant  aids  in  exposing  the  kidney  as  for  neph- 
rectomy or  nephrotomy.  In  the  most  modern  methods 
partial  or  complete  stripping  ofif  of  the  fibrous  capsule  of 
the  organ  is  undertaken.  For  this  purpose  the  assistant 
provides  scalpel  and  mouse-tooth  forceps.  The  sutures,  to 
be  passed  through  the  kidney  or  the  capsule,  or  both,  are 
of  chromicized  catgut,  silk  or  silkworm-gut,  according  to 
the  technic  employed,  and  according  as  they  are  intended 
to  be  absorbed  or  to  be  removed.  During  their  introduction 
the  assistant  is  to  hold  the  kidney  up  in  its  proper  place.  A 
gauze  tampon  may  be  called  for,  to  be  introduced  beneath 
the  lower  pole  of  the  organ. 

ABDOMINAL   ROUTE. 

The  removal  of  a  large  tumor,  or  the  removal  or  evacu- 
ation of  a  large  cyst,  of  the  kidney,  undertaken  trans-peri- 
toneally,  either  deliberately  or  in  the  course  of  an  explora- 
tory operation,  requires  the  same  preparations  as  for  lapa- 
rotomies in  general.  Several  gauze  packings,  clamps  and 
ligatures,  and  an  aneurism  needle  will  be  needed  in  dividing 
adhesions,  and  active  sponging  in  the  depth  may  be  required 
and  should  also  be  provided  for.  An  aspirating  syringe  is  to 
be  in  readiness,  and  volsella,  too,  may  be  called  into  requi- 
sition. If  a  cyst  is  to  be  dealt  with  the  assistant  should 
prepare  a  running  catgut  suture,  in  the  event  that  the  sur- 
geon may  desire  to  attach  the  sac  to  the  parietal  peritoneum, 


240  The  Surgical  Assistant. 

before  draining  it,  A  narrow  packing  will  then  also  be 
needed  to  reinforce  the  line  of  suture.  After  nephrectomy, 
the  recess  behind  the  peritoneum  may  require  the  preparation 
of  suitable  gauze  drains ;  for  the  peritoneum  itself  the  opera- 
tor may  want  a  catgut  suture. 

OPERATIONS    UPON    THE    URETER. 

To  properly  expose  the  ureter, — after  lumbar  dissection, 
or  after  lateral  abdominal  incision  and  stripping  up  of  the 
peritoneum — the  assistant  will  be  called  upon  for  the  intel- 
ligent manipulation  of  large  sharp  and  blunt  retractors.  To 
remove  a  calculus,  he  will  hand  a  scalpel,  a  slender  pair  of 
dressing  forceps  and  a  dish ;  and  after  these,  either  a  fine 
suture  of  catgut  or  silk,  or  simply  a  narrow  gauze  drain. 
To  re-unite  the  ureter,  after  injury  or  after  the  excision  of  a 
stricture,  the  assistant  should  provide  fine  sutures  of  catgut 
and  of  silk,  having  both  straight  and  small  full-curved 
needles  threaded  for  the  operator's  selection.  Silk  is  used 
for  the  deep  sutures  only  in  those  methods  of  end-to-end  or 
lateral  anastomosis  or  invagination  that  do  not  require  these 
stitches  to  pass  through  the  inner  coat  of  the  ureter.  When 
the  assistant  is  required  to  lift  up  the  ureter  in  his  forceps, 
in  order  to  help  in  the  anastomosis,  he  must  carefully  avoid 
undue  traction,  for  it  is  important  that  the  ureter  should  \not 
be  detached  from  its  bed  any  more  than  is  absolutely  neces- 
sary. 


CHAPTER  XXI. 

OPERATIONS  UPON  THE  BLADDER  ANY)  URETHRA. 

CYSTOSCOPY  IN  THE   MALE. 

For  this  manipulation  there  should  be  prepared :  the  cysto- 
scope  and  its  lighting  attachments ;  a  large  hand-syringe, 
preferably  of  glass ;  a  soft  rubber  catheter,  about  No.  21 
French;  lubrichondrin,  sterile  vaselin,  sterile  olive  oil  or 
other  lubricant ;  a  basin  of  warm  sterile  water  or  salt  solu- 
tion ;  [an  Ultzmann-  or  small  hand-syringe]  ;  [cocain  solu- 
tion, 2  per  cent.]  ;  bichlorid  of  mercury  solution,  i-iooo;  a 
few  cotton  sponges ;  a  sterile  towel  or  basin,  on  which  to  lay 
the  cystoscope ;  [ureter  catheters] ;  a  pus  basin ;  [specimen 
tumblers]  ;  [a  bistoury] ;  a  black  cloth  about  a  yard  square. 

The  patient  is  placed  in  the  "  lithotomy  position," — the  but- 
tocks at  the  end  of  the  table  and  the  legs  and  thighs  flexed. 
If  a  general  anesthetic  is  administered  a  Clover's  crutch, 
Edebohls'  or  Robb's  leg-holder,  or  a  twisted  sheet,  may  be 
applied  to  retain  the  lower  extremities.  Otherwise  it  is 
best  to  have  them  held  comfortably  in  position  by  some  one 
standing  beside  the  patient  and  facing  the  operator.  Under 
the  buttocks  should  be  placed  a  towel ;  and  the  lower  ex- 
tremities should  be  protected  from  undue  exposure  by  leg- 
gings or  some  other  covering  (<?.  g.,  pillow  cases). 

By  means  of  cotton  sponges,  the  assistant  first  cleanses  the 
glans  penis  with  soap  and  water,  and  then  with  sublimate 
solution.  If  the  operator  thinks  it  necessary,  a  few  drops  of 
the  cocain  solution  may  next  be  instilled  through  a  (lubri- 
cated) Ultzmann  syringe  (appendix,  fig.  86)  or  catheter 
which,  with  the  same  technic  of  asepsis  as  iz  described  on 
page  255  for  the  introduction  of  steel  sounds,  is  passed  into 
the  neck  of  the  bladder  and  gradually  withdrawn  as  the 

241 


242  The  Surgical  Assistant. 

cocain  is  injected,  so  that  the  latter  is  distributed  along  the 
urethral  canal.  The  catheter  is  then  passed  into  the  bladder 
and  the  urine  drained  off  into  a  pus  basin.  By  means  of  a 
hand-syringe,  the  bladder  is  irrigated  through  the  catheter 
with  sterile  water  or  salt  solution  until  the  liquid  returns 
clear ;  after  which  as  much  of  six  ounces  of  the  fluid  as  the 
bladder  will  hold,  are  injected  and  the  catheter  is  withdrawn. 
A  chair  or  stool  is  placed  in  position  for  the  examiner  at  the 
foot  of  the  table,  and  the  cystoscope  itself  is  then  made  ready 
for  use. 

If  the  instrument  is  in  carbolic  or  other  antiseptic  solu- 
tion, it  should  be  rinsed  off  in  sterile  water,  handling  it  only 
by  the  butt.  The  lighting  apparatus  (battery  or  modified 
"  street  current  ")  and  the  cystoscope  lamp  should  be  tested 
with  a  gradually  increasing  current,  the  assistant  determin- 
ing the  strength  of  the  latter  than  which  the  lamp  could 
probably  not  stand  more  without  "  burning  out."  A  milliam- 
peremeter  will  afford  a  statement  of  this  datum.  The 
instrument  is  then  dipped  in  the  lubricating  solution  and 
handed  to  the  examiner  for  insertion.  If  it  is  found  that 
the  meatus  is  too  small  to  admit  the  cystoscope,  the  bistoury 
will  be  called  into  requisition  for  the  performance  of  meat- 
otomy. 

The  cystoscope  in  position,  the  black  cloth  is  thrown  over 
the  head  of  the  surgeon  and  the  lower  end  of  the  patient, 
to  exclude  the  light — unless,  of  course,  the  room  can  be 
darkened.  The  current  is  again  turned  on  gradually  until 
the  examiner  is  satisfied  with  the  illumination,  but  it  should 
not  be  increased  beyond  the  limit  previously  determined 
upon.  If,  with  an  amperage  found  sufficient  in  the  prelimi- 
nary test,  the  field  remains  dark,  the  connections  are  faulty 
or  the  window  of  the  cystoscope  is  covered  with  blood — in 
which  latter  case  the  instrument  must  be  withdrawn  and 
cleansed,  or  the  bladder  washed  out  with  the  apparatus  in 
situ  if  an  "  irrigating  cystoscope"  is  being  employed. 

If  ureter  catheters  are  used  they  should  be  lifted  from  the 
formalin  jar  or  other  container  with  forceps  and  passed  to 
the  operator  on  a  sterile  towel  for,  being  at  best  very  difficult 


Cystoscopy.     Endoscopy.  243 

to  sterilize,  they  ought  to  be  handled  as  little  as  possible. 
If  catheters  are  left  in  the  ureters  after  the  removal  of  the 
cystoscope,  their  ends  may  be  dipped  into  test  tubes,  and 
each  catheter  and  tube  strapped  to  the  inner  surface  of  the 
corresponding  thigh  of  the  patient  with  adhesive  plaster — 
thus  to  collect  urine  from  each  kidney  separately  while  the 
patient  is  in  bed. 

During  cystoscopic  manipulations  the  patient,  if  unanes- 
thetized,  will  probably  suffer  considerable  discomfort,  and  it 
is  well  for  the  assistant  to  reassure  him  from  time  to  time  in 
a  low  voice. 

A  soon  as  the  examination  is  concluded,  the  current  is  to 
be  turned  off,  thus  giving  the  cystoscope  a  moment  to  cool 
before  it  is  withdrawn.  As  soon  after  use  as  convenient,  the 
parts  of  the  instrument  should  be  cleansed  and  sterilized,  as 
described  on  pages  103  and  108,  then  dried  and  re-assembled. 

For  Urethroscopy  (Endoscopy,  appendix,  fig.  93),  the 
preparations  are  simpler  and  the  manipulations  fewer.  The 
patient  occupies  the  extended  recumbent  position — unless 
the  posterior  urethra  is  to  be  explored,  in  which  case  the 
lithotomy  position  will  probably  be  desired.  The  glans  is  to 
be  cleansed,  and  the  light  tested,  as  in  cystoscopy.  The  endo- 
scope, lubricated,  is  handed  to  the  examiner  with  the  obtura- 
tor in  place,  the  lamp  being  attached  after  the  latter  is  with- 
drawn. Several  slender  applicators  should  be  mounted  with 
cotton,  to  mop  out  the  canal  and  to  apply  nitrate  of  silver  or 
other  medicament  to  it. 

CYSTOSCOPY    IN    THE    FEMALE. 

( Kelly- Pawlik  Method.) 

Here  are  needed :  Kelly  cystoscopes,  urethral  dilators  and 
suction  apparatus ;  urethral  calibrator ;  applicators ;  cocain 
solution  ;  catheter ;  pus  basin ;  cotton  sponges ;  sublimate  solu- 
tion ;  lubricant ;  sterile  towels ;  and  head  mirror  or  frontal 
lamp. 

The  patient  is  first  placed  in  the  lithotomy  position,  and 
tbg  vestibule  cleansed  with  a  sponge  dipped  in  sublimate 


244  The  Surgical  Assistant. 

solution.  The  labia  are  separated  with  the  thumb  and  fore- 
finger of  the  left  hand,  and  the  urine  is  withdrawn  with  a 
rubber,  glass  or  metal  catheter  held,  near  its  open  end,  be- 
tween the  right  thumb  and  middle  finger.  Before  passing 
the  catheter,  the  opening  of  the  urethra  should  be  accurately 
determined,  and  if  the  tip  of  the  instrument  inadvertently 
comes  in  contact  with  other  parts  of  the  vulva,  it  should  be 
re-sterilized.  The  ball  of  the  index  finger  is  to  be  held 
against  the  mouth  of  the  catheter  while  it  is  being  introduced 
and  again  while  it  is  being  withdrawn.  That  part  of  the 
catheter  which  is  to  enter  the  bladder  should  not  be  handled. 
Having  emptied  the  organ  [and  cocainized  the  urethra  by 
means  of  an  applicator] ,  the  assistant  hands  to  the  examiner 
the  urethral  calibrator,  and  then  a  dilator  of  the  same  size 
as  the  urethra.  Successively  larger  dilators  are  handed  until 
the  operator  is  satisfied  with  the  distention  of  the  orifice. 
Then  a  lubricated  speculum,  of  the  same  caliber  as  the  last 
dilator,  and  with  its  obturator  in  place,  is  provided.  When  it 
has  been  inserted  and  the  obturator  withdrawn,  the  patient's 
pelvis  is  elevated  on  a  cushion.  If  the  operator  notes  that 
the  bladder  does  not  satisfactorily  balloon  out,  the  assistant 
should  place  the  patient  in  the  knee-chest  position.  Indeed, 
it  is  in  this  posture  that  the  examination  is  most  often  con- 
ducted. In  it  the  patient  rests  upon  her  knees  and  shins, 
with  the  toes  over  the  end  of  the  table,  the  trunk  being  flexed 
upon  the  thighs,  and  the  upper  part  of  the  body  being  sup- 
ported upon  the  chest,  the  right  forearm  and  the  right  side 
of  the  head.  Patient  and  instrument  in  position  and  the 
room  darkened,  the  assistant  turns  his  attention  to  the  man- 
ipulation of  the  light  and  the  preparation  of  applicators. 

SUPRAPUBIC    CYSTOTOMY. 

In  addition  to  the  general  instruments,  there  are  usually 
needed:  a  hand-syringe,  catheter,  lubricant,  irrigating  solu- 
tion, and  basin,  as  for  cystoscopy;  [rubber  rectal  bag]  ;  two 
long  stout  silk  guy-sutures  threaded  on  half-curved  needles ; 
one  curved  blunt  retractor;  [a  pair  of  long,  narrow,  right- 


Suprapubic  Cystotomy.  246 

angled  blunt  retractors  ]  ;  small  sponges  on  long  handles ; 
drainage  tubes ;  narrow  gauze  packings ;  [urethral  sound]  ; 
[head  light] .  For  the  removal  of  a  calculus  there  may  also 
be  needed  stone-spoons  and  stone-forceps  (appendix,  fig. 
96)  ;  for  prostatectomy,  long-bladed  scissors  curved  on  the 
flat  and  volsella;  for  neoplasm  or  ulcer,  a  Paquelin  cautery. 

The  patient  is  placed  in  the  full  recumbent  position.  The 
pubic  region  is  shaved  and  the  skin  disinfected  in  the  usual 
way.  With  the  soft  rubber  catheter,  the  assistant  empties 
the  bladder  of  urine,  and,  if  the  latter  is  turbid,  irrigates  the 
viscus,  by  means  of  a  hand-syringe  attached  to  the  catheter, 
with  salt-,  boracic  acid-,  or  weak  (1-5,000)  sublimate-solu- 
tion until  the  fluid  returns  clear.  He  then  injects  into  the 
bladder  about  eight  ounces  (for  an  adult)  of  air  or  of  the 
solution,  according  to  the  operator's  preference,  and  with- 
draws the  catheter.  If  distention  of  the  rectum  is  also 
desired,  he  next  introduces,  beyond  the  internal  sphincter, 
the  folded  and  lubricated  rectal  bag,  inflates  it  gradually  with 
eight  to  ten  ounces  of  air  or  fluid,  and  then  clamps  the 
attached  tube.  Some  surgeons  prefer  to  distend  the  bladder 
under  the  guidance  of  the  eye,  i.  e.,  after  the  transversalis 
fascia  has  been  exposed  in  the  course  of  the  operation.  After 
these  manipulations,  the  assistant  should  "  scrub  up  "  again 
thoroughly  before  spreading  the  towels  about  the  field  of 
operation. 

The  skin  and  subcutaneous  fat  having  been  divided  in  the 
median  line  ("high  cystotomy")  or,  less  commonly,  in  a 
transverse  direction,  pronged  retractors  are  inserted  in  order 
to  expose  the  muscles.  If  the  median  dissection  is  being  fol- 
lowed, the  assistant  then,  with  mouse-tooth  forceps,  picks  up 
the  linea  alba  with  the  operator  in  order  that  it  may  be  nicked 
with  the  scalpel  and  slit  up  with  scissors  or  knife.  The 
divided  aponeurosis  is  then  drawn  aside  with  the  retractors. 
The  exposed  transversalis  fascia  is  next  similarly  picked  up 
and,  after  division,  retracted.  The  operator  having  drawn 
upwards  the  prevesical  fat  and  the  fold  of  peritoneum,  the 
assistant  holds  these  with  the  blunt  retractor  in  the  superior 
angle  of  the  wound.    The  two  guy  sutures  are  next  handed 


346 


The  Surgical  Assistant. 


to  the  operator,  one  at  a  time,  for  insertion  into  the  present- 
ing surface  of  the  bladder.  The  free  ends  of  each  suture  are 
made  even  in  length  and  are  knotted  together  or  secured  in 
hemostatic  clamps.     The  assistant  then  provides  a  narrow 


Fig.  85.  Suprapubic  cystotomy.  Bladder  exposed  and  prepared  for 
incision.  Retractors  in  sides  of  wound.  Blunt  retractor  holding  up  peritoneal 
fold  and  prevesical  fat.    Guy-sutures  inserted  in  bladder. 

scalpel  or  bistoury  and  draws  upon  one  of  the  guy  threads 
in  a  direction  away  from  that  in  which  the  operator  draws 
upon  the  other  suture. 

If  the  bladder  has  been  filled  with  fluid,  it  is  important, 
while  the  latter  is  escaping  after  the  puncture,  to  prevent 
its  entrance  into  the  perivesical  tissues,  by  using  absorbent 
gauze  and  by  keeping  bladder  and  abdominal  wall  as  much 
as  possible  in  contact.  Straight  scissors  are  needed  to 
enlarge  the  opening. 

Lithotomy.  For  the  removal  of  stones  the  surgeon  may 
need  only  his  fingers,  or  he  may  require  stone-forceps  or 
stone-spoon.  Cylindrical  speculum,  chisel  and  mallet  may, 
rarely,  be  called  into  requisition  before  an  encysted  stone  can 
be  made  small  enough  to  deliver  through  a  narrow  opening 
(Fenwick  method).  In  such  a  case  the  assistant,  with  a 
finger  in  the  rectum,  supports  the  stone  while  it  is  being 
broken. 


Suprapubic  Prostatectomy.  247 

If  the  operator  decides  to  close  the  bladder  wound,  the 
assistant  provides  him  with  a  running  suture  of  fine  chromi- 
cized  catgut  for  the  mucosa,  and  somewhat  coarser  chromi- 
cized  gut  or  silk  for  the  muscular-serous  coats ;  chromicized 
catgut  again  for  the  aponeurosis ;  and  catgut,  silk  or  aseptic 
adhesive  strips  for  the  skin.  A  short,  narrow  gauze  drain 
is  prepared  for  the  lower  angle  of  the  wound.  The  latter  is 
to  be  covered  with  an  ample  gauze  dressing,  secured  by  a 
snug  binder  or  double  spica  bandage. 

If,  however,  the  bladder  is  to  be  drained,  a  smooth,  but  not 
too  soft,  rubber  tube,  about  ten  inches  long,  is  provided. 
One  or  two  fenestrations  may  be  made  near  the  extremity 
that  is  to  enter  the  bladder.  A  few  sutures  will  probably  be 
needed  for  the  aponeurosis  and  for  the  skin,  if  not  also  for 
the  bladder.  A  split  compress,  surrounding  the  projecting 
tube,  is  placed  over  the  wound  and  covered  with  gauze  pads 
and  a  bandage  so  applied  that  the  tube  passes  through  them 
unconstricted.  A  safety-pin  or  adhesive  strap  then  secures 
the  tube  to  the  bandage  so  that  it  will  not  slip.  Another 
device  to  prevent  displacement  of  the  tube  consists  in  sur- 
rounding it,  like  a  collar,  with  a  snugly  fitting  larger  tube, 
which  is  split  in  half  through  part  of  its  length,  the  divided 
portions  being  spread  out  upon  the  skin  and  fastened  down 
with  adhesive  plaster. 

Prostatectomy.  The  assistant  mops  the  unescaped  fluid 
from  the  bladder  with  sponges.  Then,  after  handing  the 
long  curved  scissors  and  a  volsellum  to  the  operator,  he 
passes  his  left  hand  [covered  with  a  rubber  glove]  under  the 
patient's  thigh  and  introduces  the  index  finger  into  the  rec- 
tum. This  is  for  the  purpose  of  pressing  up  the  prostate 
gland  and  of  notifying  the  operator  when  his  own  finger 
approaches  the  rectum  in  the  process  of  enucleating  the  gland. 
[If  the  surgeon  desires  to  provide  perineal  drainage,  he  is 
handed  an  urethral  sound,  unlubricated.  The  assistant  then 
removes  the  towels,  separates  the  patient's  thighs  and  pro- 
vides a  scalpel  to  incise  the  perineum  where  the  tip  of  the 
sound  has  been  made  to  bulge  into  it,  and  a  stout  drainage 
tube  mounted  on  dressing  forceps,  for  introduction  as  th? 


248  The  Surgical  Assistant. 

sound  is  being  withdrawn.  See  perineal  section.']  Long 
strips  of  gauze  are  required  for  tamponing  the  bleeding  floor 
of  the  bladder,  and  others  for  the  bladder  cavity  itself. 
The  gauze  dressing  should  be  ample  and  the  bandage  tight. 
A  sandbag  may  be  placed  over  it  for  six  or  eight  hours,  to 
limit  hemorrhage. 

Neoplasm:  ulcer.  Here  the  narrow-bladed  right-angled 
retractors  are  often  needed,  and  a  strong  headlight  may  be 
very  desirable.  The  Trendelenburg  position  may  also  be- 
come necessary.  The  actual  cautery  may  be  called  into  re- 
quisition, or  applicators  dipped  in  nitrate  of  silver  solution 
or  other  medicament. 

If  the  bladder  is  resected,  the  assistant  should  expose  the 
field  well,  clamp  bleeding  vessels  and  sponge  frequently  and 
quickly.  Sutures  will  be  needed  for  the  mucosa  and  for  the 
outer  coats.  The  surgeon  may  desire  to  pack  the  bladder  in 
part  and  drain  it  with  a  tube,  or  to  pack  it  completely. 

When  suprapubic  tube  drainage  is  employed,  the  assistant 
arranges  the  following  mechanism  after  the  patient  is  re- 
turned to  bed  :  The  projecting  tube  is  connected  by  means  of 
a  glass  canula  with  a  long  piece  of  rubber  tubing  which 
passes  over  the  edge  of  the  mattress  and  is  attached  to  the 
long  arm  of  a  glass  T  tube,  fastened  to  the  mattress  with  a 
safety-pin.  From  one  of  the  short  arms  of  the  T  a  rubber 
tube  leads  into  a  carbolic  or  sublimate  solution  in  the  bottom 
of  a  pail,  placed  at  the  side  of  the  bed.  The  other  short  arm 
is  connected  with  tubing  leading  from  an  irrigating  bottle 
suspended  near  the  head  of  the  bed,  and  containing  a  weak 
sublimate  solution.  The  flow  of  this  solution  from  the  bottle 
through  the  short  arms  of  the  T  tube  syphons  the  urine  out 
of  the  bladder.  By  constricting  the  tube  leading  from  the 
irrigator  with  a  hemostat,  clothespin,  hairpin,  or  other  device, 
the  rate  of  flow  may  be  reduced  so  that  the  solution  escapes 
into  the  pail  drop  by  drop — thus  making  replenishment 
necessary  only  at  comparatively  long  intervals  (figure  86). 
The  tubing  running  from  the  bladder  drain  to  the  glass  T 
should  be  sufficiently  long  and  flexible  to  allow  the  patient 
to  move  about,  and  it  should  be  prevented  from  kinking 


Drainage  of  the  Bladder. 


249 


over  the  edge  of  the  mattress  by  fastening  under  it  at  that 
point  a  piece  of  stiff  curved  cardboard  or  other  device.  A 
glass  S  tube  may  be  introduced  into  the  discharging  pipe 


Fig.  86.     Arrangement  of  syphon  for  suprapubic  drainage  of  the  bladder. 


near,  or  inside  of,  the  pail  to  form  a  trap,  but  this  is  not 
essential. 

Perineal  drainage  requires  no  syphonage.  The  perineal 
tube,  held  in  place  with  a  safety-pin  under  the  bandage,  if 
not  actually  stitched  to  the  skin,  is  attached  by  means  of  a 
glass  canula  to  a  tube  leading  under  one  of  the  patient's 
knees,  and  into  a  bottle  containing  an  antiseptic  solution, 
suspended  under  the  edge  of  the  bed. 

In  both  forms  of  drainage  it  is  desirable  to  keep  the  centre 
of  the  glass  coupler  uncovered  by  tubing,  in  order  to  observe 
the  passage  of  blood  clots,  etc, 


250  The  Surgical  Assistant, 

internal  urethrotomy. 

The  appliances  needed  depend  upon  the  character  of  the 
stricture  and,  in  part,  upon  the  technics  of  the  operator. 
Speaking  generally,  it  is  well,  if  possible,  to  have  ready 
the  instruments  necessary  for  the  internal  division  of  all  sizes 
of  stricture  since,  for  example,  after  cutting  through  one 
stricture,  a  tighter  one  may  be  discovered  more  deeply 
located.  The  following  supply  of  instruments  (illustrated  in 
Appendix  2,  pages  347,  348)  will  meet  all  conditions :  Otis 
urethrometer ;  probe-pointed  bistoury,  or  Gouley's  beaked 
knife ;  a  set  of  steel  sounds,  up  to  No.  35  French,  or  even  40 
French ;  an  assortment  of  filiform  whalebone  bougies,  of 
bougies  a  boule  and  of  olive-pointed  bougies ;  a  soft  rubber 
catheter,  about  No.  18  French  ;  "  English  catheters,"  Nos.  25, 
30  and  35  French ;  hand-syringe ;  urethrotome  of  the  Otis 
type;  urethrotome  of  the  Maisonneuve  type;  [cocain  or 
eucain  solution]  ;  boracic  acid-  or  weak  sublimate-solution ; 
lubricant  for  sounds  and  catheters.  Since  perineal  drainage 
may  become  necessary  even  when  not  originally  intended,  the 
asisistant  should  also  have  at  hand :  a  scapel ;  a  pair  of 
medium-sized  sharp  retractors ;  a  pair  of  small  sharp  retrac- 
tors ;  [a  small  round  blunt  retractor]  ;  two  mouse-tooth  for- 
ceps ;  one  anatomical  forceps ;  one  long  dressing  forceps ; 
hemostats  ;  needle  holder ;  half-curved  needles ;  two  or  three 
silk  sutures ;  catgut  ligatures ;  a  gorget  or  grooved  director ; 
straight  and  curved  scissors ;  a  probe ;  a  catheter  or  piece  of 
smooth  tubing  of  the  caliber  of  30  F. ;  narrow  packings ; 
safety-pins ;  perineal  dressing. 

The  patient  is  placed  in  the  lithotomy  position  with  the 
back  flat  upon  the  table  and  the  median  line  of  the  perineum 
kept  always  in  the  strict  vertical.  After  shaving,  the  penis, 
scrotum,  perineum  and  buttocks  are  cleansed  with  soap  and 
water  and  then  with  sublimate  solution.  Only  when  a 
patient  is  fully  narcotized  should  a  stiff  brush  or  alcohol  or 
ether  he  used  in  disinfecting  the  genitals.  The  urethra  distal 
to  the  stricture  may  theii  be  washed  out  with  the  irrigating 


Internal  Urethrotomy.  Combined  Urethrotomy.  251 

solution.  If  a  local  anesthetic  is  to  be  employed  this  is  next 
instilled  by  the  assistant. 

Instruments  for  determining  the  site  and  caliber  of  the 
stricture,  or  strictures,  are  first  handed.  The  urethrometer 
may  suffice  for  the  purpose,  or  there  may  be  required  an 
assortment  of  bougies  a  boule  or,  for  narrow  passages,  of 
filiform  bougies.  If  only  fine  instruments  will  pass,  one  of 
the  filiform  bougies  belonging  to  the  Maisonneuve  urethro- 
tome is  handed  to  the  surgeon  for  insertion ;  then  the 
grooved  stafiF  of  the  instrument  is  provided  for  attachment 
to  this  filiform  guide,  and  then  the  wedge-bearing  stylet  it- 
self, to  slide  along  the  stafif  and  cut  the  stricture  from  with- 
out inward.  For  strictures  of  larger  caliber,  or  if  desired 
for  tight  strictures  after  division  with  the  Maisonneuve  in- 
strument, a  urethrotome  of  the  Otis  type  is  handed,  with 
which  to  cut  from  within  outward.  While  the  stricture  is 
being  cut  with  any  form  of  urethrotome,  the  assistant,  seiz- 
ing the  glans  penis,  should  hold  the  organ  on  the  stretch 
in  the  horizontal  plane  and  in  the  median  line  of  the  body. 
A  lubricated  steel  sound,  of  the  size  to  which  the  stricture 
has  been  cut,  is  handed  to  the  surgeon  after  he  withdraws  the 
urethrotome. 

If  perineal  drainage  is  to  be  provided  (Combined  Urethro- 
tomy) the  assistant,  standing  on  the  patient's  left,  passes  his 
right  forearm  over  the  abdomen  and  lifts  up  the  scrotum 
with  the  fourth  and  fifth  fingers  of  the  right  hand.  Between 
the  thumb  and  the  index  and  middle  fingers  of  the  same 
hand  he  takes  from  the  operator  the  handle  of  the  steel  sound 
left  in  situ  in  the  urethra,  and  holds  it  in  such  a  manner 
(viz.,  inclined  toward  the  abdomen),  that  the  penis  is  nearly 
vertical,  and  the  sound  bulges  in  the  perineum  (fig.  87).  An 
incision  having  been  made  down  to  the  sound,  retractors  are 
inserted  into  the  urethral  wound  in  the  perineum  and  the 
staff  is  withdrawn.  Then  [a  grooved  director  and]  a  drain- 
age tube  mounted  in  the  beak  of  a  dressing  forceps  are 
handed. 

The  tube  in  place,  the  retractors  are  withdrawn  and  a 


252 


The  Surgical  Assistant. 


narrow  packing  may  be  provided  for  insertion  aronnd  the 
drain.  To  hold  the  latter  in  position  it  should  be  transfixed 
by  a  large  safety-pin.  A  suture  may  also  be  called  for  to 
anchor  the  rubber  to  the  skin.  A  split  compress  is  applied 
beneath  the  safety-pin,  and  loose  gauze  is  laid  about  the  tube. 
A  T  bandage,  preferably  of  unbleached  muslin,  is  then  ap- 
plied.   Of  this  the  arms  encircle  the  waist,  while  the  tail  is 


Fig.  87.  Mannerof  holding  scrotum,  penis  and  urethral  sound  in  external 
urethrotomy. 

[Note. -Straps  of  leg-holders  are  here  drawn  outside  of  leggings  to  show 
method  of  arranging  them — properly  the  leggings  (which  are  split)  should 
cover  straps  and  leg-holders.] 

brought  from  behind  the  patient's  body  over  the  perineal 
dressing  and  pinned  in  front  to  the  other  arms.  This  peri- 
neal strip  is  perforated  to  admit  the  passage  of  the  drainage 
tube  and  split  further  forward  to  surround  the  scrotum  and 
penis. 

EXTERNAL  URETHROTOMY  AND  "  PERINEAL  SECTION." 

The  instruments,  etc.,  to  be  at  hand  are  those  mentioned 
above  for  internal  urethrotomy  and  perineal  drainage,  and  in 
addition  grooved  urethral  staffs  (Syme's,  Wheelhouse's, 
etc.,— appendix,  figs.  94,  95).  The  patient  is  placed  in  the 
lithotomy  position.     It  is  desirable  to  have  at  hand  a  flat 


External  Urethrotomy — Perineal  Section.     2^)3 

cushion  upon  which  the  buttocks  may  be  raised  if  neces- 
sary. In  addition  to  the  disinfection  of  the  field  as  described 
above,  it  is  well  to  sponge  out  the  rectum.  The  assistant 
should  seat  himself  at  the  foot  of  the  table  on  the  right 
of  the  operator.  If,  however,  there  is  no  second  helper  to 
hold  up  the  scrotum,  penis  and  staff,  the  assistant  should 
stand  on  the  patient's  left  side,  lifting  the  genitals  with  his 
right  hand  and  employing  his  left  hand  in  aiding  at  the 
wound  and  in  handing  instruments. 

Syme's  Operation.  A  grooved  staff  is  handed  to  the 
operator  at  first  or  after  he  has  sounded  the  urethra  with 
bougies.  Syme's  staff  has  a  narrow  tip  to  enter  the  stricture, 
a  shoulder  to  rest  on  the  face  of  the  stricture  and  a  wider 
portion  above  the  shoulder.  The  staff  having  been  inserted 
its  handle  is  taken  from  the  operator  and  held,  with  the  penis 
and  scrotum,  in  the  manner  described  above  and  illustrated 
in  figure  87.  A  narrow-bladed  scalpel  is  then  provided. 
The  staff  having  been  exposed  and  the  stricture  divided,  the 
instrument  is  to  be  withdrawn  upon  signal  from  the  surgeon. 
A  full-sized  sound  is  handed  to  test  the  canal. 

Then  a  full-sized  gum-elastic  catheter  is  handed  to  provide 
drainage.  The  operator  may  elect  to  pass  this  through  the 
entire  urethral  canal,  or  to  insert  it  through  the  perineal 
wound.  In  either  case  a  grooved  director  may  be  called  for 
to  guide  the  catheter  into  the  bladder.  If  it  is  passed  at  the 
meatus  the  wound  is  lightly  packed  and  covered  with  a 
simple  gauze  dressing  held  by  a  T  binder;  the  tip  of  the 
catheter  is  secured  to  the  penis  with  adhesive  strips,  or  to 
the  dressing  with  tapes.  If  the  catheter  is  passed  through 
the  perineum,  it  should  be  transfixed  by  a  safety-pin  near  the 
wound,  and  cut  off  three  inches  beyond;  a  narrow  gauze 
strip  may  be  needed  to  insert  about  the  tube,  and  split  com- 
press, loose  gauze  and  T  binder  are  applied  as  described 
under  "  combined  urethrotomy."  When  the  patient  is  in 
bed,  the  catheter  drain  is  to  be  coupled  to  a  tube  leading  into 
a  pail  or  bottle. 

Wheelhouse's  Operation.  A  Wheelhouse  staff  is  handed 
>vith  the  groove  towards  the  operator,  When  it  has  been 


254  The  Surgical  Assistant. 

inserted  it  is  held  by  the  assistant  as  in  figure  87.  Scalpel, 
mouse-tooth  forceps  and  hemostats  are  then  passed.  When 
the  urethra  has  been  divided  two  small  hooks,  or  volsella  or 
guy  threads,  are  needed  to  hold  it  open  laterally.  The  re- 
tractor or  volsellum  on  the  right  side  is  to  be  held  by  the 
assistant.  The  latter  relinquishes  the  staff  to  the  surgeon. 
\Mien  the  instrument  is  re-adjusted  so  that  its  button  tip  en- 
gages in  the  upper  angle  of  the  urethral  wound,  the  assistant 
takes  the  handle  again  and  draws  upwards  upon  it  gently. 
Next  a  right-angled,  probe-pointed,  grooved  director  and  a 
narrow  scalpel  are  handed  for  dividing  the  stricture  while 
the  wound  is  thus  held  open.  Artificial  light  may  be  needed 
for  this  procedure.  The  remaining  steps  are  essentially  as 
in  assistance  at  Syme's  operation. 

External  Urethrotomy  unthoitt  a  Guide — Cock's  Opera- 
tion. The  scrotum  and  penis  are  held  up  and  the  patient's 
body  is  steadied  so  that  the  median  line  of  the  perineum 
is  kept  vertical,  while  the  surgeon  plunges  a  sharp,  narrow- 
bladed  scalpel  towards  the  apex  of  the  prostate.  When  the 
knife  is  withdrawn,  a  probe-pointed  director  is  handed,  and 
then  a  large  gum-elastic  catheter,  straightened  on  its  stylet. 
The  catheter  is  cut  short  after  insertion,  and  the  perineal 
dressing  applied. 

Median  and  Lateral  Lithotomy.  These  require,  essenti- 
ally :  grooved  sounds  of  size  suited  to  the  patient's  age,  scal- 
pel, probe-pointed  bistoury,  grooved  director,  and  stone  for- 
ceps. The  assistant,  standing  on  the  patient's  left  side,  holds 
the  grooved  sound  (straight  or  curved)  in  the  exact  position 
directed  by  the  surgeon — usually  drawn  well  up  and  wath 
the  handle  tilted  towards  the  abdomen  in  order  to  bring  the 
membranous  urethra  close  to  the  perineum.  The  director  is 
needed  after  the  scalpel,  and  then  the  stone  forceps.  The 
drainage  and  the  dressing  are  as  above  described. 

Perineal  Prostatectomy.  The  ordinary  dissection  instru- 
ments, long-handled  sponges,  volsella,  one  or  two  sounds 
and  long  scissors  are  needed.  Rectal  and  bladder  tractors 
in  the  form  of  rubber  bags,  etc.,  are  used  by  some  operators. 

The  a§§istant,  seated  ^t  the  right,  will  be  QQneerned  almost 


Urethral  Instrumentation.  255 

entirely  in  the  manipulation  of  wound  retractors,  in  sponging 
and  in  securing  bleeding  vessels.  Strips  of  (iodoformized) 
gauze  about  four  inches  wide  should  be  in  readiness  for 
packing  the  wound. 

It  is  often  necessary  that  the  surgical  assistant  should 
know 

How  to  pass  a  Steel  Sound  or  other  Unyielding  Urethral 
Instrument.  Gentleness  and  cleanliness  are  of  utmost  im- 
portance. The  hands  should  be  disinfected,  and  the  sound 
made  aseptic  by  boiling.  Lifted  from  the  sterilizer  it  is 
rinsed  in  sterile  water  and  dried  with  a  sterile  towel,  on 
which  latter  it  may  be  laid  until  needed.  One  should  be  able 
to  pass  a  sound  with  either  hand,  and  from  either  side  of  the 
patient,  or  while  standing  between  the  thighs  flexed  in  the 
lithotomy  position.  By  choice,  however,  the  operator  stands 
upon  the  left  of  the  patient,  who  lies  in  the  recumbent  pos- 
ture with  the  head  raised  and  the  thighs  slightly  flexed  and 
separated.  The  penis  is  held  in  the  left  hand.  The  prepuce 
is  retracted  and  the  glans  cleansed  by  means  of  absorbent 
cotton,  first  with  soap  and  water,  and  then  with  sublimate 
solution.  The  sound  is  taken  in  the  right  hand,  touching 
the  instrument  always  at  its  handle  only,  and  its  tip  is  dipped 
in  sterile  olive  oil  or  glycerin  or  anointed,  by  means  of  the 
towel,  with  lubrichondrin  or  vaselin.  The  back  of  the  right 
hand  rests  on  the  patient's  abdomen,  just  below  the  umbili- 
cus. The  sound  is  lightly  poised  between  the  thumb  and  the 
index  and  middle  fingers,  with  its  tip  towards  the  penis  and 
the  concavity  of  its  curve  towards  the  floor.  The  third  and 
fourth  fingers  of  the  left  hand  lifting  the  penis  by  the  corona 
glandis,  the  thumb  and  index  finger  press  open  the  meatus 
so  that  the  sound  will  come  into  contact  with  the  mucous 
membrane  only,  as  its  tip  is  introduced.  The  two  hands  are 
now  made  to  approach,  the  sound  being  gently  urged  into 
the  penis — by  scarcely  more  pressure  than  its  own  weight — 
and  the  penis  being  drawn  up  over  the  sound.  The  left  hand 
is  now  withdrawn  and  the  handle  of  the  sound  is  carried 
down  slowly  at  right  angles  to,  and  in  an  arc  occupying  the 


256  The  Surgical  Assistant. 

midplane  of,  the  body.  When  the  handle  reaches  the  level 
of  the  thighs,  it  is  transferred  to  the  left  hand,  by  which  it  is 
slowly  depressed  between  the  limbs.  A  resistance  is  felt  as 
the  tip  of  the  sound  enters  the  prostatic  urethra.  This  yields 
after  a  moment  when,  with  a  further  depression  of  the 
handle  and  slight  urging  of  the  sound,  the  instrument  slips 
past  the  neck  of  the  bladder.  In  withdrawing,  the  handle  is 
to  be  carried  throusfh  the  same  arc  in  the  reverse  direction. 


CHAPTER  XXII. 
OPERATIONS  IN  AND  ABOUT  THE  VAGINA. 

The  table,  prepared  with  drainage  pad,  etc.,  as  shown  in 
figure  14,  is  located,  if  possible,  so  that  the  light  falls  upon 
its  lower  end  and  in  the  general  direction  of  its  length.  A 
drainage  receptacle  is  arranged  at  the  foot  of  the  table,  and 
here  also  are  placed  two  stools  or  chairs — one  for  the  opera- 
tor on  the  left,  the  other  for  the  assistant  on  the  right.  A 
low  table  (or  board  laid  on  chairs)  is  so  placed  that  the 
assistant  can  reach  the  instruments  upon  it  with  his  right 
hand,  without  moving  from  his  seat. 

In  the  performance  of  curettage,  trachelorrhaphy,  etc., 
there  is  occasionally  employed  the 

Sims'  Position  (figure  100).  The  patient  lies  on  her  left 
side  with  the  left  buttock  at  or  just  overhanging  the  end  of 
the  table  near  the  corner  corresponding  to  the  operator's 
left.  The  head  lies  near  the  right  side  of  the  table.  The  left 
thigh,  at  an  angle  of  about  70  degrees  with  the  body,  is  al- 
most parallel  with  the  lower  end  of  the  table,  the  correspond- 
ing leg  projecting  beyond  the  table.  The  right  thigh,  over- 
lapping the  left,  is  flexed  more  acutely,  the  right  foot  lying 
about  over  the  left  calf.  The  patient's  back  is  thus  directed 
somewhat  upwards  and  towards  the  operator's  left.  When 
this  position  is  used,  a  nurse  stands  at  the  patient's  back  to 
hold,  with  one  or  with  both  hands,  a  Sims  or  Sims-Munde 
speculum  (appendix,  fig.  11 1)  which  she  draws  upon  in  such 
a  manner  that  the  posterior  vaginal  wall  is  approached  to 
the  sacrum,  thus  to  expose  the  cervix  uteri. 

Usually  the  ordinary  lithotomy  position  is  employed.  The 
patient  is  laid  on  her  back  with  the  buttocks  in  the  drainage 
pad,  and  just  projecting  over  the  table.  The  lower  extremi- 
ties are  separated  and  flexed  and  held  by  means  of  knee  sup- 

257 


358 


The  Surgical  Assistant. 


ports,  Edebohls'  leg-holders,  the  twisted  sheet  or  Robb's  leg- 
holder,  a  Clover's  crutch,  or  simply  by  the  hands  of  a  second 
assistant.  They  are  to  be  covered  with  [sterile]  leggings  or 
pillow  cases  or  wrapped  in  sterile  towels. 

Preparation  of  the  Field.  For  curettage,  drainage  of  a 
pelvic  abscess  or  similar  minor  operation  involving  no  sutur- 
ing, the  operator  will  probably  not  require  that  the  patient 


Fig.  88.    Arrangement  of  table,  towels  and  chairs  for  perineal  operation. 
Legs  held  in  Edebohls'  holders.     Weighted  speculum  in  place. 


be  shaved.  In  other  cases,  however,  the  hair  should  be  care- 
fully removed  from  the  labia  and  perineum,  the  mons 
veneris  being  shaved  or  not  according  to  the  nature  of  the 
operation. 

After  removing  from  the  vagina  with  forceps  or  by  means 
of  irrigation  any  excessive  secretion  that  may  be  present,  the 
assistant  scrubs  the  canal  with  soap  and  water.  For  this 
purpose  he  may  use  a  jeweler's  brush.  This  has  no  bristles 
at  the  tip,  and  therefore  hardly  cleanses  the  presenting  sur- 
face of  the  cervix ;  moreover,  the  bristles  may  lacerate  the 
vaginal  mucosa.  It  is  better  therefore,  in  most  cases,  to  use 
a  sea-sponge  or  gauze  mop  mounted  in  the  tip  of  a  clamp  or 
pair  of  dressing  forceps ;  or  the  assistant  may  simply  use 


Disinfection  of  the  Vagina  and  Perineum.     259 

two  fingers  to  rub  the  soapsuds  over  the  cervix  and  vaginal 
walls.  The  vagina  is  then  washed  out  with  sublimate  solu- 
tion, 1-5,000.  This  may  be  directed  into  the  canal  from  an 
irrigator,  or  poured  in  from  a  pitcher.  The  pitcher  is  held 
just  over  the  vulva,  and  the  vagina  is  made  to  receive  the 
fluid  by  hooking  the  perineum  out  with  a  finger  introduced 
over  the  fornix.  By  alternately  stretching  down  and  press- 
ing in  the  perineum,  the  canal  may  be  filled  and  emptied 
several   times.     The  hypogastrium,   external  genitals,  per- 


FiG.  89.    Manner  of  applying  Clover's  crutch.    (Appendix,  Fig.  97.) 

ineum,  buttocks  and  inner  surface  of  the  thighs  are  then 
thoroughly  scrubbed  with  soap  and  water,  wiped  ofif  and 
v/ashed  with  sublimate  solution,  i-iooo  or  1-2000.  The 
urethral  orifice  is  easily  lacerated  by  the  bristles  of  a  hand- 
brush,  and  if  it  be  even  only  bruised  the  patient  will  com- 
plain of  dysuria  for  some  days  thereafter.  A  soft  cotton 
mop  should  therefore  be  used  for  cleansing  the  vestibule. 
The  labia  may  be  pressed  together  during  the  scrubbing  of 
the  skin,  to  prevent  the  entrance  of  gpapsnds  into  the  va^in^, 


260  The  Surgical  Assistant. 

If  this  happens,  however,  the  canal  may  receive  a  final 
douche.  Fluid  remaining  in  the  posterior  fornix  should  be 
mopped  out,  or  evacuated  by  depressing  the  perineum. 

The  assistant  having  disinfected  the  operating  field  and  his 
own  hands  and  forearms,  dons  his  gown.  He  lays  a  towel 
over  each  of  the  patient's  thighs,  another  across  the  abdomen 
and  a  fourth  one  over  the  edge  of  the  table  and  under  the 
buttocks.  Seating  himself  on  the  right,  he  spreads  a  towel 
on  the  operator's  lap  and  one  on  his  own — these  to  hold  in- 
struments from  time  to  time.    Where  a  single  assistant  is  re- 


FiG.  90.    Disposition  of  operator  (on  the  left)  and  of  assistant  (on  the  right) 
in  vaginal  and  perineal  operations.    Note  positions  of  hands  and  forearms. 

quired  to  perform  additional  duties,  as  for  example  to  aid  in 
supporting  the  legs^  it  is  sometimes  advantageous  for  him  to 
remain  standing.  In  any  case,  he  will  do  well  to  wear,  under 
his  gown,  a  stout  rubber  apron  that  reaches  quite  to  the  floor, 
to  protect  his  garments  from  being  wet. 

CURETTAGE. 

The  instruments  (appendix,  figs.  98-112),  should  be  ar- 
ranged on  the  table  in  the  order  in  which  they  are  to  be 


Curettage  of  the  Uterus.  261 

handed,  viz. :  specula,  volsellum,  uterine  sound,  small  cervi- 
cal dilator,  large  dilator,  curettes,  intra-uterine  irrigating 
tip  and  attached  piece  of  rubber  tubing,  and  slender  dress- 
ing forceps  or  uterine  "  packer,"  and,  for  the  assistant's  use, 
sponge  holders,  anatomical  forceps  and  straight  scissors. 
With  the  two  last  named  instruments,  there  should  be  lifted 
from  the  jar  and  prepared  two  strips  of  plain  or  iodoform- 
ized  gauze  an  inch  wide,  and  another  strip  about  three 
inches  wide.  Neither  in  preparing  these  strips  nor  in  pass- 
ing them  to  the  operator  need  the  assistant  touch  them  with 
his  fingers.  A  vulva  pad  of  gauze  and  a  T  binder  will  be 
needed  for  the  dressing,  but  they  may  be  applied  after  the 
patient  is  put  to  bed.  An  irrigating  solution  of  bichlorid 
of  mercury,  i-io,ooo  to  1-5,000,  or  of  plain  water,  and 
having  a  temperature  of  120  degrees,  F.,  must  also  be 
prepared. 

If  the  vulvar  outlet  is  large,  no  speculum  may  be  required, 
the  cervix  being  exposed  merely  by  drawing  it  down  with  the 
volsellum.  Otherwise  the  operator  is  handed  first  the  specu- 
lum, e.  g.,  a  self-retaining  weighted  speculum  (appendix, 
figure  108)  which,  as  its  name  implies,  will  not  have  to  be 
held  in  place.  Then  there  are  handed  in  succession  the  vol- 
sellum, the  uterine  sound  and  the  small  dilator.  In  passing 
these  the  assistant  holds  them  by  their  shanks,  their  shafts 
in  the  direction  of  the  vagina  and  their  handles  towards  the 
operator.  As  the  dilator  is  handed  to  the  surgeon,  he  is  re- 
lieved of  the  sound.  If  the  dilators  have  set-screws,  the 
assistant  should  note  before  passing  them  that  they  are  so 
placed  that  the  handles  can  at  once  be  manipulated.  When 
the  small  dilator  is  withdrawn,  it  is  to  be  taken  from  the 
operator's  hand  and  the  larger  one  substituted.  After  com- 
pleting the  dilatation  (a  process  that  is  not  required  when  the 
cervical  canal  is  already  open,  e.  g.,  immediately  after  a 
miscarriage) ,  the  surgeon  is  ready  for  the  curette.  In  operat- 
ing for  endometritis,  he  will  probably  desire  first  a  small 
blunt  curette,  then  a  small  sharp  one,  and  then  the  same 
or  a  narrower  sharp  instrument  for  the  cervix.  For  the  re- 
moval of  placental  tissues  of  considerable  size,  the  surgeon 


262  The  Surgical  Assistant. 

will  use  placental  forceps  or  (and)  a  large  blunt  curette,  or 
his  finger  only.  Irrigating  curettes  are  used  by  some  opera- 
tors ;  when  needed,  they  are  to  be  attached  to  the  tube  lead- 
ing from  the  irrigating  bag.  During  the  performance  of  the 
operation,  the  assistant  usually  need  only  sponge  out  the 
vagina  from  time  to  time.  It  will  be  well  for  him  to  save 
the  bits  of  tissue  collected  by  the  sponge  for  the  operator's 
subsequent  inspection.  A  specimen  dish  may  be  kept  at 
hand  for  the  collection  of  material  brought  away  with  the 
curette.  The  surgeon  may  desire  the  assistant  to  hold  the 
volsellum  occasionally ;  this  he  is  to  do  in  such  a  manner  that 
the  cervix  is  drawn  towards  the  urethra. 

The  curetting  completed,  the  intra-uterine  douche  is  to 
be  supplied.  After  attaching  the  "  recurrent  "  douche  point 
(e.  g.,  Bozemann's),  the  assistant  should  allow  the  solution 
to  run  upon  his  left  hand, — without  touching  the  instrument 
to  it,  however — in  order  to  determine  that  the  first,  cool,  por- 
tion of  the  fluid  is  drained  off,  before  passing  the  canula  to 
the  operator.  After  the  douche  the  vagina  is  mopped  out,  if 
necessary,  and  the  first  narrow  strip  of  gauze  is  handed.  It 
is  to  be  seized  by  a  corner  in  the  very  tip  of  the  slender 
uterine  dressing  forceps,  and  frayed  strands  picked  off  with 
thumb  forceps.  If,  in  its  passage  from  the  instrument  table 
to  the  uterus,  the  gauze  touches  the  vulva,  the  vagina  or  even 
the  surface  of  the  cervix  itself,  it  should  be  discarded.  To 
prevent  the  escape  of  the  gauze  with  each  withdrawal  of  the 
forceps  from  the  uterus,  the  assistant  may  hold  the  packing 
in  the  cervix  by  the  pressure  of  a  uterine  sound.  Indeed,  a 
sound  may  be  used,  probe-like,  to  introduce  the  gauze.  The 
employment  of  a  uterine  gauze-packer  obviates  the  tendency 
of  the  strip  to  come  out  with  the  introducing  instrument ; — 
one  end  of  the  gauze  is  mounted  on  the  spiked  end  of  the 
stylet,  thrust  through  the  tube,  and  thus  handed  to  the  sur- 
geon. 

After  the  first  strip  has  been  used  (to  remove  all  shreds 
of  tissue  not  evacuated  by  the  irrigation),  the  second  one  is 
handed.  When  this  is  in  place  the  volsellum  is  withdrawn, 
and  the  wider  gauze  packing,  referred  to  above,  is  provided 


Trachelorrhaphy. 


263 


for  the  vagina.     Gauze  vulva  pad  and  T  binder  constitute 
the  dressing. 

In  the  performance  of  Munde's  discission  and  dilatation 
a  long,  straight,  slender,  probe-pointed  bistoury  is  needed  be- 
fore the  gauze  drain,  about  an  inch  and  a  half  wide,  is  put 
int(5  the  uterus. 

TRACHELORRHAPHY. 

This  requires,  in  addition  to  the  instruments  for  curettage, 
a  long  pair  of  mouse-tooth  forceps;  [a  tenaculum]  ;  a  scal- 
pel ;  a  long  pair  of  sharp-pointed  scissors,  curved  on  the  flat ; 


Fig.  9L  Disposition  of  surgeon,  assistant  and  anesthetist  in  trachelor- 
rhaphy. The  operator  has  taken  the  volsellum  in  his  left  hand  while  introduc- 
ing the  stitches.  Assistant's  right  hand  manipulating  sponge  ;  his  left  hand  is 
here  shown  through  the  operator's  arm  to  indicate  method  of  holding  posterior 
vaginal  retractor  (spade). 


needle  holder;  "cervix  needles"  (see  appendix,  figure  27) 
or  stout  full-curved  needles  of  about  the  same  length ;  a  few 
artery  clamps ;  and,  if  silver  wire  is  used  for  stitching,  the 
wire  twister,  scissors,  shield  and  "  counterpresser." 

Whatever  material  be  used — silkworm-gut,  silk,  chromi- 
cized  catgut  or  silver  wire,  four  or  five  sutures,  each  about 


264 


The  Surgical  Assistant. 


nine  inches  long,  should  be  prepared  in  advance.  Ligature 
material  should  be  at  hand,  although  it  is  not  often  needed. 
While  the  surgeon  is  preparing  the  wound  surface  with 
mouse-tooth  forceps  or  tenaculum  and  scalpel  or  scissors, 
the  assistant  draws  the  cervix  down  by  seizing  the  volsellura 
with  his  right  hand.  With  his  left  hand  he  sponges  the 
wound,  or  better  yet,  has  directed  against  it  from  a  short  dis- 
tance above,  intermittent  spurts  of  fluid  from  the  irrigator. 


Fig.  92.    Trachelorrhaphy.    Assistant  sponging  wound  and  clamping  sutures. 

As  the  stitches  are  being  drawn  through,  the  assistant 
should  exercise  counterpressure  against  the  cervix  near  the 
emerging  needle  point,  by  means  of  some  stiff  instrument, 
e.  g.,  a  counterpresser,  dressing  forceps,  curette  or  the  flat 
end  of  a  grooved  director.  The  ends  of  each  suture,  unless 
secured  at  once,  should  be  grasped  in  a  hemostat,  or  lifted 
up  in  the  assistant's  right  hand.  When  all  are  in  place  they 
are  fed  to  the  operator,  one  by  one  in  regular  order,  to  be 


Vaginal  Hysterectomy.  265 

tied.  Assistance  at  adaptation  may  be  needed,  as  with  other 
wounds.  A  uterine  sound  is  to  be  handed  next  to  test  the 
patency  of  the  cervical  canal.  Then  the  uterine  gauze  drain 
is  passed. 

VAGINAL    HYSTERECTOMY. 

The  instruments  to  be  laid  out  are :  a  weighted  speculum 
or  short  perineal  retractor;  a  pair  of  short,  right-angled 
lateral  retractors ;  a  pair  of  long  narrow  retractors ;  two  or 
more  volsella ;  a  catheter ;  a  bladder  sound ;  scalpels ;  blunt 
scissors,  curved  on  the  flat;  long-handled  sharp  scissors, 
curved  on  the  flat;  aneurism  needles,  right  and  left;  long 
hemostatic  forceps;  an  assortment  of  strong,  straight  and 
curved  "  broad  ligament  clamps  " ;  needle  holder ;  medium- 
sized,  half-curved  needles;  a  few  finer  full-curved  needles 
for  use  in  case  of  injury  to  the  bladder;  several  sponge 
handles;  two  mouse-tooth  forceps.  Several  heavy  catgut 
(No.  4  or  No.  5)  and  heavy  silk  ligatures  about  sixteen 
inches  long  should  be  ready,  and  two  sutures  of  No.  2  cat- 
gut may  be  prepared  for  closing  the  vaginal  vault.  The  as- 
sistant's work  will  lie  in  the  management  of  the  retractors, 
in  sponging  and  in  handing  and  removing  instruments.  The 
perineal  retractor  is  first  handed  and  then  a  volsellum.  After 
these  the  surgeon  may  desire  a  strip  of  gauze  for  the  cervix 
and,  probably,  a  second  volsellum.  If  by  depressing  the  cer- 
vix he  indicates  that  he  intends  incising  anteriorly  first,  he 
should  be  handed  the  bladder  sound,  which  the  assistant 
is  to  hold  in  position  if  used,  and  then  the  blunt  scissors. 
The  lateral  retractors  are  now  inserted  if  a  nurse  is  at  hand 
to  help  in  holding  the  vagina  open, — the  assistant  manipulat- 
ing the  right  lateral  retractor  and  the  bladder  sound,  the 
nurse  holding  the  perineal  and  the  left  retractor.  When  the 
bladder  sound  is  no  longer  needed  the  assistant  has  his  left 
hand  free  for  sponging.  The  long  artery  clamps  may  be 
needed  for  bleeding  in  the  vaginal  vault.  If  the  operator  lifts 
up  the  cervix,  and  begins  posteriorly  instead  of  anteriorly, 
the  sound  will  not  be  needed,  of  course, 


266  The  Surgical  Assistant. 

When  the  cervix  has  been  freed  all  around,  a  long  narrow 
retractor  should  be  handed  for  msertion  between  the  bladder 
and  uterus.  This  is  to  be  drawn  up  strongly.  (Whether  the 
surgeon  will  use  clamps  or  ligatures,  or  both,  in  securing  the 
broad  ligaments  he  will  have  to  indicate  to  the  assistant.  If 
he  use  ligatures,  then  when  he  draws  the  uterus  to  the  left  he 
should  be  provided  with  a  ligature  (catgut  or  silk,  as  he  may 
desire)  mounted  in  a  right-handed  aneurism  needle,  and  z'ice 
I'crsa.  As  the  ligature  pierces  the  broad  ligament,  the  assist- 
ant should  grasp  and  hold  the  loop  with  forceps  until  the 
operator,  after  withdrawing  the  carrier,  relieves  him  of  it. 
Usually  three  ligatures  are  inserted  on  each  side,  the  broad 
ligament  being  cut  and  the  uterus  dragged  down  further 
after  tying  each  pair.  If  clamps  are  used,  one  to  three  are 
needed  on  each  side,  the  operator  either  replacing  them  with 
ligatures  or  leaving  them  in  situ.  When  clamps  are  not  left 
on,  catgut  sutures  are  used  for  closing,  in  part,  the  vaginal 
roof,  the  broad  ligament  pedicles,  especially  when  tied  with 
silk,  being  drawn  out  for  inclusion  in  the  stitches.  A  gauze 
drain  is  needed. 

In  an  operation  of  this  sort,  through  an  aperture  that  is 
relatively  small,  the  assistant  will  help  most,  not  by  trying  to 
do  much,  but  by  endeavoring  at  all  times  to  render  necessary 
aid  without  obstructing  the  surgeon's  manipulations.  In  re- 
tracting, sponging,  etc.,  he  should  use  that  hand  which  will 
least  interfere  and  should  dispose  his  forearms  with  the  same 
consideration. 

DRAINAGE    OF    PELVIC    ABSCESS,    ETC. 

Here  are  needed :  bivalve,  Sims,  or  weighted  speculum,  or 
vaginal  retractors ;  volsellum ;  aspirating  syringe  and  long, 
stout  needle ;  [grooved  director]  ;  dressing  forceps ;  long- 
handled  sharp-pointed  scissors,  preferably  curved  (on  the 
fiat)  ;  gauze  packings  two  inches  wide ;  gauze  for  vaginal 
tamponade ;  specimen  dish ;  pus  basin  ;  and  irrigator.  Two 
stout  pieces  of  rubber  tubing  about  ten  inches  long  should 
be  prepared,  fenestrae  being  cut  near  the  tip.     A  T  tube  is 


Pelvic  Abscess. 


567 


sometimes  used.  This  is  made  by  stitching  the  end  of  a 
long  piece  of  tubing  around  an  opening  made  in  the  center  of 
one  side  of  a  second  piece  two  inches  long.  This  short  arm 
is  to  be  doubled  up  in  the  dressing  forceps  when  the  tube  is 
inserted. 

The  speculum  or  retractors  and  volsellum  are  first  handed, 
then  the  aspirator  [and  after  this  the  grooved  director]  and 


Fig.  93.    Drainage  of  pelvic  abscess.    Showing  manner  of  forcibly  retract- 
ing vaginal  walls,  and  method  of  inserting  drainage  tube  in  dressing  forceps. 


scissors.  Dressing  forceps  may  be  desired  to  enlarge  the 
opening,  and  a  pus  basin  should  be  held  to  catch  the  evacu- 
ated fluid  if  large  in  amount.  One  or  two  drainage  tubes 
or  a  T  tube  are  then  handed  to  the  operator,  grasped  by  the 
end  in  the  tips  of  long-bladed  dressing  forceps,  as  shown  in 


268  The  Surgical  Assistant. 

figure  93.  Here  the  author's  cervix-elevating  attachment  to 
the  anterior  vaginal  retractor  (appendix,  fig.  109),  may  be 
substituted  for  the  volsellum  to  better  put  the  posterior  for- 
nix on  the  stretch,  and  open  the  wound  for  the  easy  insertion 
of  the  drain.  The  irrigating  tip  is  attached  to  the  inserted 
tube  in  order  to  wash  out  the  cavity.  A  strip  of  gauze  may 
be  desired  in  place  of,  or  in  addition  to,  the  tubing.  The 
latter  is  cut  off  just  beyond  the  vulva,  and  a  piece  of  gauze 
is  inserted  into  the  vagina. 

PLASTIC  OPERATIONS  UPON  THE  VAGINA  AND  PERINEUM. 

These  require:  volsella;  two  "tissue"  or  mouse-tooth  for- 
ceps ;  full-bellied  scalpels ;  long-handled,  sharp-pointed  scis- 
sors curved  on  the  flat ;  artery  forceps ;  sponge  handles ;  sut- 
uring instruments  and  materials ;  irrigator  to  keep  the  field 
free  of  blood  by  means  of  intermittent  ^ets  of  a  small  stream 
of  fluid,  directed  from  above.  For  the  vagina  there  should 
be  prepared  long  (continuous)  sutures  of  silk  or,  more  often, 
of  No.  I  chromicized  catgut  in  medium-sized,  sharp,  stout, 
half-curved  needles.  A  Peaslee  or  other  "  handled  needle  " 
(appendix,  fig.  28),  is  often  used  for  passing  the  silkworm- 
gut,  silk,  silver  wire  or  horsehair  perineal  sutures. 

ANTERIOR   COLPORRHAPHY   FOR   CYSTOCELE. 

The  assistant's  arrangement  and  preparation  of  the  tables, 
the  patient  and  himself  are  as  described  for  curettage.  The 
vulva  and  perineum  should  be  shaved,  however. 

In  addition  to  the  instruments  above  mentioned,  there  may 
be  needed  a  weighted  speculum  or  posterior  vaginal  tractor, 
a  bladder  sound  and  a  catheter.  The  speculum  is  handed 
first,  although,  since  the  tissues  are  relaxed  and  easily  ex- 
posed, it  is  not  always  needed.  Then  there  are  passed  to 
the  operator,  one  after  the  other,  four  volsella  with  which  to 
seize  the  anterior  vaginal  wall  at  points  on  the  circumference 
of  what  is  to  be  the  area  of  denudation.  In  order  to  outline 
and  then  remove    this  area  it  must  be  evenly  exposed  by 


Anterior  Colporrhaphy. 


269 


traction  on  the  volsella — or  on  guy  sutures  that  may  be  used 
as  substitutes  for  the  volsella.  A  second  assistant  (nurse)  is 
therefore  very  useful  here.  Facing  the  operator,  and  stand- 
ing at  his  left,  she  holds  steadily  the  uppermost  volsellum 
vertically  (with  her  left  hand)  and  the  one  fastened  on  the 
left  side  horizontally  (with  her  right  hand).  The  assistant 
draws  upon  the  volsellum  at  the  right  side  with  his  left  hand 
— the  right  hand  being  thus  left  free  for  the  manipulation  of 
mouse-tooth    forceps.      The    fourth,    lowermost,    volsellum 


Fig.  94.  Dissection  of  cystocele  flap.  A,  assistant's  right  hand  ;  B,  assist- 
ant's left  hand  ;  C,  surgeon's  right  hand ;  D,  surgeon's  left  hand.  Volsella 
being  held  here  by  other  assistants. 


exercises  traction  by  gravity  as,  in  its  place,  a  guy  suture 
may  be  made  to  do  by  attaching  a  heavy  clamp  to  its  ends. 

Lacking  a  second  helper,  the  outlining  and  denudation 
must  be  done  alternately  on  one  side  and  the  other  while  the 
assistant  holds  the  uppermost  volsellum  and  the  irrigator  tip 


270  The  Surgical  Assistant, 

with  his  right  hand,  and  first  one  and  then  the  other  lateral 
volsellum  with  his  left  hand  (taking  care  to  keep  the  left 
forearm  out  of  the  operator's  way). 

It  is  important  that  traction  upon  the  volsella  should  be 
made  symmetrically,  to  avoid  distortion  of  the  denudation 
area,  and  that  the  volsella  should  be  held  flat,  i.  e.,  in  such 
a  manner  as  not  to  twist  the  tissues. 

Mouse-tooth  or  "  tissue  "  forceps  is  handed  to  the  sur- 
geon and,  according  to  his  preference,  scalpel  or  scissors. 
If  the  assistant  have  a  hand  free  he  too  takes  a  pair  of 
mouse-tooth  forceps  and  with  this  aids  in  raising  the  flap 
that  is  being  dissected  up.  That  is  to  say,  he  applies  the  for- 
ceps at  the  flap  edge,  near  the  point  seized  by  the  operator, 
and  moves  the  instrument  when  the  latter  does  his,  as  the  dis- 
section proceeds  from  one  place  to  another.  In  order  that  his 
hand  may  not  obstruct  the  field,  the  assistant  should  apply 
his  forceps  at  a  point  above  that  seized  by  the  surgeon  when 
the  right  side  is  being  denuded  (see  figure  94),  while  when 
the  dissection  is  on  the  left  side  he  applies  his  forceps  at  a 
point  below  the  surgeon's  and  may  shift  it  to  his  left  hand 
to  accomplish  this  conveniently.  He  should  raise  the  flap 
evenly  with  the  operator  to  help  him  to  avoid  "  buttonholing" 
it,  and  if  he  observes  an  island  of  mucosa  that  has  not  been 
removed  he  may  indicate  it  to  the  operator  by  lifting  it  up 
with  his  forceps.  Bleeding  vessels  should  be  seized  with 
hemostats,  each  to  be  left  attached  until  it  is  reached  by 
sutures — ligatures  being  undesirable  and  only  occasionally 
necessary. 

The  entire  area  denuded  and  irrigated  with  hot  sublimate 
or  other  solution,  traction  on  the  laterally  placed  volsella, 
continued  symmetrically  to  prevent  infolding  and  distortion, 
is  relaxed  in  order  to  accommodate  the  introduction  of 
sutures.  These  are  ordinarily  applied  in  tiers — unless  the 
denuded  surface  is  quite  narrow — and  a  single  strand  of 
chromicized  catgut,  if  sufficiently  long,  will  suflice  for  the 
purpose.  Introduced  and  tied  at  the  upper  angle,  the  assist- 
ant seizes  the  short,  free  end  of  the  gut  with  his  right  hand, 
^nci  removes  the  yolsellum  at  that  point.    Each  loop  of  the 


Anterior  Colporrhaphy. 


271 


continuous  suture  is  in  turn  seized  and  lifted  up  between  the 
thumb  and  forefinger  of  the  assistant's  right  hand,  and  is 
released  only  as  the  next  loop  is  drawn  through  (figure  95). 
As  each  loop  is  being  drawn  the  centre  of  the  tissue  it  in- 
cludes should  be  pressed  in  with  forceps  in  the  assistant's 
left  hand,  to  facilitate  adaptation.  The  same  manipulations 
are  repeated  as  the  second  tier  is  being  sewed,  the  assistant's 


Fig.  95.    Holding  loops  of  suture  in  anterior  colporrhaphy.    Volsella  being 
held  by  nurse. 


left  hand  holding  the  suture  taut  if  it  is  introduced  from  be- 
low upwards.  With  the  last  tier  (interrupted  or  continuous) 
mouse-tooth  forceps  are  manipulated,  as  in  other  wounds,  to 
secure  accurate  coaptation.  As  in  the  dissecting,  so  during 
the  suturing,  intermittent  irrigation  may  be  employed  to 
keep  the  field  clean. 


272 


The  Surgical  Assistant. 


POSTERIOR    COLPORRHAPHY ;    PERINEORRHAPHY. 

In  addition  to  the  other  preparations  of  the  field,  the  rec- 
tum should  be  cleansed. 

There  are  handed  to  the  operator  three  volsella  (or  trac- 
tion sutures).  That  one  fastened  to  the  center  of  the  pos- 
terior vaginal  wall  is  to  be  drawn  upon  vertically  towards  the 
urethra,  those  applied  laterally  at  the  margin  of  the  vulva  are 


Fig.  96.    Dissection  of  rectocele  flap.    A,  assistant's  right  hand  ;  B,  assist- 
ant's left  hand  ;  C,  surgeon's  right  hand  ;  D,  surgeon's  left  hand. 

to  be  drawn  apart  horizontally — thus  exposing  and  stretch- 
ing out  the  triangular  area  to  be  denuded.  If  a  nurse  is  at 
hand  she  is  to  hold  the  volsella  or  traction  sutures  at  the  apex 
and  left  extremity  of  the  base  of  the  triangle,  respectively ; 
while  the  assistant  holds  the  volsellum  at  the  right  side  of  the 


Posterior  Colporrhaphy.     Perineorrhaphy.     273 

vulva.  If  no  second  helper  is  present,  the  assistant  must 
manipulate  the  volsella  himself,  two  at  a  time ;  while  the 
operator  dissects  the  area  between  them.  The  base  line  of 
the  triangle  must  be  put  well  on  the  stretch  while  it  is  being 
marked  out  with  scalpel  or  scissors.  Similarly  the  apex  of 
the  triangle  must  be  drawn  well  up  and  steadied  in  the 
median  line,  both  for  the  outlining  of  the  sides  of  the  area 
and  for  the  subsequent  dissection  and  suturing. 

The  assistant's  technics  in  these  procedures  are  essentially 


Fig  97.  Dissection  of  rectocele  flap.  A,  assistant's  right  hand  ;  B,  assist- 
ant's left  hand  ;  C,  surgeon's  right  hand  ;  D,  surgeon's  left  hand,  index  finger  of 
which  pushes  up  perineum  through  rectum. 

as  described  for  anterior  colporrhaphy  (q.  v.).  Thus, 
with  mouse-tooth  forceps  he  lifts  up  an  edge  of  the  flap  near 
the  point  seized  by  the  operator,  beginning  at  the  base  line, 
and  moves  his  forceps  with  the  surgeon's.  In  dissecting  up 
the  base  of  the  triangle  the  assistant's  forceps  is  applied 


274 


The  Surgical  Assistant, 


to  the  right  of  the  surgeon's.  As  in  anterior  colporrhaphy 
it  is  applied  above  the  operator's  when  the  right  side  is 
being  detached,  below  it  when  the  left  side  is  dissected. 
Bloodvessels  exposed  beneath  the  flap  should  be  clamped 
before  they  are  cut,  if  possible. 

Some  operators  perform  the  entire  denudation  with  the 
left  index  finger  in  the  rectum.  The  assistant  must  then 
manipulate  both  the  tissue  forceps,  thus  preparing  area  after 


Fig.  98.    Posterior  colporrhaphy.    Assistant's  right  hand  catching  up  the 
loop  of  suture  to  maintain  apposition  of  edges. 

area,  in  regular  order,  for  dissection.  He  applies  the  forceps 
at  the  base  line  first,  beginning  at  the  right,  and  then  lifts 
the  flap  up  on  the  other  sides,  working  towards  the  center 
of  the  triangle.  Even  traction  is  essential  to  prevent  but- 
tonholing, as  is  also  elevation  of  the  edge  of  the  flap  in  such 
a  manner  that  the  tissue  beneath  is  in  view  of  the  operator. 
When  the  denudation  is  performed  in  strips,  with  scissors. 


Posterior  Colporrhaphy.     Perineorrhaphy,     275 

it  is  important  for  the  assistant  to  seize  each  successive  por- 
tion of  the  mucosa  in  order  that  no  undenuded  island  is  over- 
looked. 

The  assistant's  manipulations  during  the  introduction  of 
the  tier  sutures  within  the  vagina  are  sufficiently  described 
under  anterior  colporrhaphy.  As  the  last  tier  approaches 
the  vulva  the  traction  strand  at  the  apex  is  to  be  cut  off  and 
the  vaginal  floor  dropped  back. 

The  services  of  the  assistant  in  the  treatment  of  the  peri- 
neal surface  depend  in  part  upon  the  suture  method  adopted 
and  in  part  upon  the  extent  of  the  perineal  injury.  If  the 
perineal  wound  is  short  and  superficial  there  may  be  required 
only  two  or  three  interrupted  stitches  of  silk  or  No.  2  cat- 
gut, to  be  mounted  in  medium-sized  full-curved  needles. 

If  there  has  been  a  tear  into  or  through  the  sphincter  ani 
or  even  to  a  considerable  depth  into  only  the  other  muscles, 
the  assistant  should  not  hand  the  other  perineal  sutures  until 
these  structures  have  been  repaired.  If  the  torn  muscle 
edges  have  not  previously  been  sufficiently  exposed  and 
"  freshened,"  forceps  and  sharp-pointed  curved  scissors,  or 
scalpel,  are  now  provided  and  the  wound  is  held  widely  open. 
Interrupted  sutures  of  No.  2  chromicized  gut  in  small  half- 
curved  needles  are  required  for  the  rectal  mucous  membrane, 
the  sphincter  and  the  levator  ani  et  vaginae.  The  assistant 
helps  in  lifting  the  ends  of  these  tissues  into  the  path  of  the 
needle,  and  cuts  each  suture  short  after  it  is  tied. 

If  the  muscular  injury  has  not  been  deep,  the  through  and 
through  perineal  sutures  may  be  handed  at  once.  These  are 
usually  of  silkworm-gut,  silver  wire  or  stout  silk.  Large 
full-curved  needles  may  be  used,  or  the  operator  may  prefer 
a  Peaslee  perineal  needle.  In  either  case  the  assistant  should 
steady  the  tissues  with  his  hands  as  they  are  being  transfixed, 
the  surgeon's  left  hand  being  occupied  in  picking  up  the 
deeper  structures  into  the  path  of  the  needle.  The  Peaslee 
needle  is  handed  to  the  surgeon  unthreaded.  As  its  point 
appears  on  the  left  side  of  the  perineum  each  time  that  it  is 
thrust  through,  the  assistant  passes  a  suture  (e.  g.,  of  silk- 
worm-gut) through  its  eye,  to  be  drawn  back  through  the 


276 


The  Surgical  Assistant. 


wound  (figure  99),  When  coarse  silver  wire  is  used,  there 
is  first  inserted  in  the  needle  a  silk  carrying  loop,  by  means 
of  which  the  wire,  bent  sharply  upon  itself  at  the  end,  is 
dragged  through.  The  corresponding  ends  of  each  perineal 
suture  are  to  be  clamped  in  hemostats  until  all  are  in  place. 
As  each  is  tied,  or  secured  with  button  and  shot,  the  assistant 


Fig.  99.    Insertion  of  perineal  sutures.    With  left  hand  assistant  is  passing 
suture  strand  through  eye  of  Peaslee  needle. 


coaptates  the  skin  edges.  Intermediate  sutures  of  catgut 
may  be  needed  to  secure  satisfactory  skin  approximation. 
An  antiseptic  powder  (e.g.,  iodoform)  is  usually  dusted 
on  the  wound.  A  strip  of  gauze  is  laid  in  the  vagina,  and  a 
gauze  pad  is  secured  over  the  perineum  with  a  T  binder. 


CHAPTER  XXIII. 


RECTAL  OPERATIONS. 


Position  of  the  Patient.  For  purposes  of  examination,  the 
assistant  should  place  the  patient,  according  to  the  surgeon's 
choice,  in  either  the  lithotomy  or  the  knee-chest  position,  in 
Sims'  position  with  the  upper  natis  retracted  by  the  assist- 
ant's or  the  patient's  hand  (figure  lOo),  or  upon  the  belly 
with  a  pillow  under  the  hypogastrium  and  the  lower  extrem- 
ities hanging  over  the  end  of  the  table  and  supported  by  the 
assistant.  All  of  these  postures  are  employed,  more  or  less, 
for  operations  also,  but, — except  for  resection  of  the  rectum 


Fig.  100.    Showing  use  of  Sims'  position  for  rectal  examination. 


by  the  sacral  route,  where  there  is  used  the  lateral  or  the 
prone  position  or  the  dorsal  posture  with  a  pillow  under  the 
lumbar  spine,  and  the  pelvis  lifted  above  and  beyond  the 
table, — there  is  most  often  employed  the  lithotorhy  position. 
The  arrangement  of  the  operating  and  accessory  tables  and 
the  disposition  of  the  patient,  the  surgeon  and  the  assistant 
are  then  just  as  described  for  perineal  and  vaginal  opera- 
tions. 

Preparation    of    the    Field.     The    perineum    should    be 
shaved.     In  order  next  to  cleanse  the  rectum  the  assistant 

277 


278 


The  Surgical  Assistant. 


may  find  it  necessary  to  first  stretch  the  sphincter  ani  to 
permit  the  introduction  of  the  sponge.  The  patient  must  be 
"  well  under  "  the  anesthetic,  and  will  ordinarily  groan  dur- 
ing the  dilating  process  unless  the  narcosis  is  profound.  The 
thumbs,  anointed  with  soap  or  vaselin,  and  with  their  dorsal 
surfaces  apposed,  are  introduced  into  the  rectum,  as  far  as, 
or  just  beyond,  the  knuckles.  With  the  other  fingers,  pur- 
chase may  be  secured  on  the  buttocks.  The  thumbs  are  then 
drawn  slowly  and  steadily  apart  until  the  sphincter  is  felt  to 
'■  give  "  and  the  anus  gapes.  This  should  be  accomplished 
without  any  laceration  of  the  mucosa.  After  rectal  opera- 
tions, more  especially  after  operations  involving  dilatation  of 


Fig.  101.     Manner  of  stretching  the  sphincter  ani. 


the  sphincter,  it  is  often  the  case  that  the  patient  is  unable  to 
void  urine  voluntarily  for  a  day  or  more.  This  is  particu- 
larly apt  to  occur  if  the  stretching  has  been  done  in  a  vertical 
direction,  i.  e.,  towards  the  urethra  and  towards  the  coccyx. 
It  is  wise,  therefore,  for  the  assistant  to  stretch  only  later- 
ally, i.  e.,  to  draw  his  thumbs  towards  the  tubera  ischii. 

The  rectum  is  then  swabbed  out  with  soap  and  water  by 
means  of  a  sponge  or  cotton  mop  fastened  in  a  sponge 
carrier.     With  the  anus  held  open,  the  soapsuds  are  next 


Rectal  Operations. 


279 


washed  out  of  the  bowel  by  an  irrigation  with  warm  subli- 
mate solution,  1-5000.  Only  a  small  amount  of  the  solution 
should  be  used,  for  if  any  be  retained  in  the  gut  it  may  be 
expelled  later  during  the  operation,  to  the  annoyance  of  the 
operator.  To  prevent  any  such  expulsion  of  retained  fluid 
or  of  feces,  and  also  for  use  as  a  tractor  to  expose  internal 
hemorrhoids,  there  may  be  introduced  into  the  rectum — 
either  by  the  assistant  after  he  has  completed  the  preparation 
of  the  field  by  disinfecting  the  perineum,  or  by  the  surgeon 
at  the  beginning  of  the  operation — a  "  sponge  on  a  string." 
This  is  made  by  attaching  a  double  strand  of  heavy  silk  or 
catgut  to  the  center  of  a  gauze-  or  sea-sponge,  either  by 
transfixion  or,  better,  by  means  of  a  double  knot  or  of  a  clove- 
hitch  (see  figure  2,7)-  After  cleansing  the  field,  the  assistant 
disinfects  his  hands  and  slips  a  gown  over  his  rubber  apron, 
then  spreads  towels  over  the  end  of  the  table  and  on  the 
patient's  thighs,  and  taking  his  seat  on  the  operator's  right, 
lays  a  towel  across  the  surgeon's  lap  and  another  upon  his 
own. 

The  Rectal  Dressing.     After  the  operation   for  hemor- 
rhoids,   polypus,    prolapus,    etc.,    some    surgeons    dust   the 


Fig.  103.     "Tampon  canula." 

wound  with  iodoform  and  introduce  simply  an  anodyne  sup- 
pository, others  employ  a  simple  strip  of  gauze,  while  still 
others  pass  into  the  bowel  a  "  tampon  canula."  This  latter 
has  the  advantages  of  preventing  oozing  of  blood  by  gentle 
pressure  against  the  wound,  of  allowing  any  considerable 
hemorrhage  to  show  itself  in  the  outer  dressings,  and  of 


280 


The  Surgical  Assistant. 


making  painless  the  escape  of  flatus  and  the  introduction  of 
enemata.  It  should  be  prepared  in  advance  by  the  assistant, 
and  may  be  made  of  any  size,  but  is  ordinarily  about  three 
inches  long.  A  piece  of  stiff  rubber  tubing  of  that  length  is 
smeared  with  vaselin  and  wrapped  about  with  several  layers 
of  iodoformized  gauze  of  the  same  width.  Vaselin  is  rubbed 
in  over  each  turn  of  the  gauze.  One  end  of  the  tampon  is 
then  trimmed  in  the  form  of  a  truncated  cone,  as  shown  in 


Fig.  103. 
T  binder. 


Rectal   dressings — tampon   canula,   split  compress,  gauze  pad, 


the  illustration,  the  surface  is  smoothed  with  a  final  applica- 
tion of  vaselin,  and  the  distal  end  is  transfixed  with  a  large 
safety-pin  to  prevent  the  canula  from  slipping  entirely  into 
the  bowel. 

The  external  dressing  consists  of  a  split  compress  when 
the  "  tampon  canula  "  is  employed,  of  one  or  more  pads  of 
gauze  and  a  T  binder,  as  indicated  in  figure  103.    The  gauze 


Hemorrhoids. 


281 


may  be  pinned  to  the  binder  to  prevent  slipping  of  the 
dressing. 

RADICAL    OPERATION    FOR    HEMORRHOIDS, 

There  should  be  ready :  rectal  speculum  ( e.  g.,  Sims'  bi- 
valve), pile  clamp  (appendix,  fig.  115),  Paquelin  cautery, 
two  mouse-tooth  forceps,  a  few  artery   forceps,    [dressing 


Fig.  104.  Clamp  and  cautery  operation.  A,  assistant's  right  hand ;  B,  as- 
sistant's left  hand  ;  C,  surgeon's  left  hand  ;  D,  surgeon's  right  hand. 

forceps],  scissors  curved  on  the  flat,  [a  scalpel],  needles 
and  needle  holder  for  suturing  operations,  sponges,  a  few 
sponge  handles,  No.  2  catgut  ligatures,  other  ligature  and 
suture  material  as  described  below,  "  sponge  on  a  string," 
iodoform  duster,  tampon  canula,  split  compress,  gauze  pads 
and  binder.  If  there  is  no  second  assistant,  these  articles 
may  all  be  arranged  on  a  low  table  within  easy  reach. 

Clamp  and  Cautery  Operation.  (Smith's.)  The  "  sponge 
on  a  string  "  having  been  inserted  into  the  rectum,  the  assist- 
ant places  in  the  operator's  lap  the  pile  clamp,  curved  scis- 


282 


The  S'urgical  Assistant. 


sors,  and  a  pair  of  mouse-tooth  forceps,  and  a  pair  of  forceps 
in  his  own  lap.  By  gentle  traction  upon  the  string,  if  this  be 
necessary,  or  by  everting  the  mucous  membrane  with  his 
fingers  on  each  side  of  the  anus,  the  assistant  exposes  the 
hemorrhoids.  The  surgeon  having  lifted  a  pile  at  one  point, 
the  assistant  seizes  it  near  the  further  extremity  in  such  a 
manner  that  the  clamp  can  be  properly  applied  beneath  the 
forceps  and  in  the  direction  of  the  axis  of  the  rectum  (figure 
104).     The  blades  of  the  clamp  closed,  the  assistant  relin- 


FiG.  105.    ClaiTip  and  cautery  operation.    A,  assistant's  right  hand  ;  B,  sur- 
geon's right  hand  ;  C,  surgeon's  left  hand. 


quishes  his  forceps  and  screws  tight  the  fixation  nut  of  the 
clamp.  Then  he  wipes  the  pile  dry  with  a  mounted  sponge, 
and  rests  the  latter  just  beyond  the  end  of  the  clamp  to  pre- 
vent damage  by  slipping  of  the  cautery.  If  the  surgeon  does 
not  remove  the  hemorrhoid  with  scissors  (and  then  sear  the 
stump)  a  towel  is  placed  over  his  right  hand  in  which  to 
receive  at  once  the  handle  of  the  Paquelin  cautery.     The 


Hemorrhoids.  283 

platinum  should  be  kept  at  a  cherry  red  heat  only — i.  e.,  not 
"  white  hot,''  yet  hot  enough  to  thoroughly  sear  the  pile 
stump  without  sticking  in  its  passage  across  it. 

The  cauterization  completed,  the  assistant  sponges  charred 
bits  from  the  surface  of  the  clamp  and  unscrews  the  nut 
to  release  it.  When  the  other  piles  have  been  similarly 
treated,  he  gently  withdraws  the  sponge  tampon  from  the 
rectum  and  again  gently  everts  the  mucous  membrane  that 
it  may  receive  a  dusting  of  iodoform  crystals.  After  the 
iodoform  box  there  should  be  handed  the  tampon  canula  [or 
gauze  drain  and  a  probe],  split  compress,  gauze  pads  and  T 
binder,  in  the  order  named. 

Clamp  and  Suture  Operation.  (Thelwell  Thomas.) 
After  each  hemorrhoid  is  clamped  and  cut  off,  the  assistant 
hands  to  the  surgeon  a  twelve-inch  strand  of  No.  2  catgut, 
on  each  end  of  which  is  a  straight  needle,  and  with  his  left 
hand  relieves  the  operator  of  the  clamp  while  the  sutures 
are  passed  from  side  to  side  and  knotted.  Hemostats  and 
ligatures  are  occasionally  needed  also. 

Crushing  Operation.  The  assistant  observes  the  same 
technic  as  in  the  previous  methods,  the  "  screw-crusher " 
being  used  instead  of  the  clamp.  No  cautery  is  necessary, 
the  pile  being  amputated  with  scissors  or  scalpel  just  before 
the  crusher  is  released. 

Ligature  Operation.  (Allingham.)  As  in  the  other  meth- 
ods, the  assistant  aids  in  elevating  each  pile  with  mouse- 
tooth,  hemostatic  or  volsellum  forceps,  while  the  mucosa  near 
the  base  is  circumcised  with  curved  scissors  [or  scalpel]. 
The  assistant  then  hands  a  No.  3  catgut  or  stout  silk  liga- 
ture, and  drags  upon  the  pile  with  both  the  forceps  while  the 
surgeon  ties  the  hemorrhoid  and  cuts  it  off.  If  it  is  large 
enough  to  need  ligating  in  segments,  a  ligature  of  double 
length  is  to  be  threaded  on  a  large  surgical  needle,  or  passed 
through  a  Peaslee  needle,  with  either  of  which  the  centre  of 
the  pile  is  transfixed. 

Excision  of  the  Pile-Bearing  Area  (Whitehead's  Opera- 
tion.) If  after  stretching  the  sphincter  there  is  not  suffi- 
cient prolapse,  with  the  spread  fingers  of  the  left  hand  the 


284  Thb  Surgical  Assistant. 

assistant,  by  pressure  on  each  side  of  the  anus,  causes  the 
hemorrhoidal  area  to  protrude.  With  forceps  in  the  right 
hand  he  aids  the  surgeon  in  picking  up  the  mucous  mem- 
brane near  the  skin  border,  in  order  that  it  may  be  separated 
here  with  blunt  scissors  and  dissected  up.  The  assistant's 
technics  are  much  the  same  as  in  assisting  at  vaginal  plastic 
operations.  Spurting  vessels  must  be  clamped,  and  tied  or 
twisted.  After  each  portion  of  the  dissected  cuff  of  mucous 
membrane  is  cut  away,  a  silk  suture  will  be  needed  to  attach 
the  corresponding  cut  edge  of  mucosa  to  the  skin,  the  assist- 
ant helping  in  the  adaptation  with  his  mouse-tooth  forceps. 
The  dressing  is  the  same  as  in  the  other  methods  of  operat- 
ing. 

INTERNAL    DIVISION    OF    STRICTURE    OF    THE    RECTUM. 

Here  are  needed :  speculum ;  [straight  steel  sound]  ;  scal- 
pel ;  stout,  long-bladed,  probe-pointed  bistoury ;  long  curved 
and  straight  scissors ;  long  dressing  forceps ;  slender  clamps ; 
sponges  in  carriers ;  ligatures ;  an  assortment  of  Wales'  rec- 
tal bougies  (appendix,  fig.  ii6)  ;  drainage  tubing;  and 
gauze.  The  diseased  area  should  be  kept  well  exposed,  well 
lighted  and  sponged  dry.  After  the  stricture  is  divided,  suc- 
cessively larger  bougies  are  needed.  The  internal  dressing 
consists  of  a  large  tampon  canula.  If,  however,  there  is 
much  hemorrhage  from  vessels  that  cannot  be  ligated,  there 
should  be  quickly  prepared,  instead,  a  "  petticoated  tube  " 
(canule  a  chemise).  This  is  made  by  stitching  an  end  of  a 
piece  of  stout  rubber  tubing  in  an  opening  made  in  the  center 
of  a  large  square  of  gauze.  After  it  is  passed,  like  a  closed 
umbrella,  into  the  rectum,  long  strips  of  gauze  are  handed  to 
the  surgeon  with  which  to  pack  tight  the  space  between  the 
tube  and  the  square  of  gauze,  as  in  the  manner  of  filling  a 
"  Mikulicz  bag." 

FISTULA  IN  AND, 

The  instruments  required  are :  speculum ;  slender,  flexible 
probe ;  stout  probe ;  grooved  director ;  narrow  scalpel ; 
straight  and  curved  scissors ;  mouse-tooth  forceps ;  sharp  re- 


Stricture  of  the  Rectum.     Fistula.  285 

tractors ;  Volkmann  spoons ;  sponge  carriers ;  hemostats ; 
[needles;  needle  holder;  and  sutures].  Peroxid  of  hydro- 
gen or  a  colored  solution  (e.  g.,  of  methylene  blue)  is  some- 
times used,  as  an  injection,  to  aid  in  demonstrating  all 
branching  sinuses.     The   assistant's   duty   is   to  keep   the 


Fig.  106.    "  Canule  a  chemise."    (Petticoated  tube.) 

wound  well  retracted  and  dry,  and  from  time  to  time  to  hold 
a  probe  or  director  in  the  fistulous  tract.  The  dressing  con- 
sists, usually,  in  a  gauze  packing  and  compress,  with  or 
without  a  tampon  canula. 


CHAPTER  XXIV. 
OPERATIONS  UPON  THE  EXTREMITIES. 

AMPUTATIONS. 

For  Major  Ampntatioiis  the  assistant  should  have  ready: 
one  or  two  large  scalpels ;  straight  and  curved  scissors ;  two 
mouse-tooth  forceps;  four  sharp-pronged"  retractors;  one 
dozen  artery  forceps ;  a  stout  probe ;  dressing  forceps ;  full- 
curved  and  half-curved  needles ;  needle  holder ;  amputating 
knife;  double-edged  interosseous  knife*  ("ratlin")  for  am- 
putations through  the  forearm  or  leg ;  raspatory ;  periosteal 
elevator  ;  large  flat  saw  ;  Gigli  wire  saw  ;  [metacarpal  saw]  ; 
[lion-jaw  bone  forceps]  ;  Liston's  or  other  bone-cutting  for- 
ceps ;  [rongeur] ;  anatomical  forceps  ;  tourniquet ;  [Horsley's 
bone  wax];  "cloth  retractor";  ligatures  and  sutures;  irri- 
gating salt  solution ;  drainage  tubing ;  sterile  rubber  tissue ; 
six  or  eight  sea-sponges  in  a  basin  of  hot  sublimate  solution ; 
an  abundance  of  sterile  gauze ;  absorbent  cotton ;  several 
four-inch  bandages ;  [starch  bandages]  ;  splints ;  and  the 
usual  supply  of  towels,  sheets  and  other  accessories.  The 
paraphernalia  for  intravenous  infusion  should  also  be  at 
hand  as  for  any  operation  that  may  entail  great  shock  or 
loss  of  blood. 

The  catlin  is  not  essential,  and  may  be  replaced  by  the 
amputating  knife  itself,  if  of  narrow  blade,  or  by  a  scalpel ; 
the  saw  may  be  omitted  for  disarticulations ;  while  the  special 
transfixion  pins  must  be  included  with  the  other  instruments 
in  preparing  for  an  amputation  at  the  hip  or  shoulder  by 
Wyeth's  method. 

The  Tourniquet.  While  Petit's  apparatus, — consisting  of 
a  stout  strap  with  pad  and  buckle  and  two  plates  to  be  separ- 

*  See  Appendix  2,  pages  339  and  346. 

286 


Amputations. 


287 


ated  by  a  screw, — and  other  older  forms  are  still  occasionally 
used,  bandages,  tubing  or  bands  of  rubber  are  most  employed 
for  constricting  the  limb.  They  are  to  be  sterilized  in  boiling 
water,  after  the  assistant  has  assured  himself  that  they  are 
strong  and  sound.  This  last  is  important,  since  rubber  often 
submitted  to  heat,  or  not  kept  in  air-tight  containers  between 
operations,  is  apt  to  prove  rotten  at  the  critical  moment.  For 
the  shoulder  or  the  upper  part  of  the  thigh  there  should  be 


Fig.  lOr.    Two-tailed  cloth  retractor.        FiG.  108.    Three-tailed  cloth  retractor. 


ready  Esmarch's  constrictor, — consisting  of  a  flat  rubber 
band  with  a  hook  at  one  end  and  a  chain  at  the  other, — or 
a  piece  of  stout,  soft  (black)  rubber  tubing  two  feet  long; 
while  for  constriction  at  other  points,  except  the  digits,  the 
Martin  rubber  bandage  should  be  prepared. 

The  Cloth  Retractor  is  designed  to  hold  the  soft  parts  out 
of  the  way  while  the  bone  is  being  sawn.     It  consists  of  a 


288  The  Surgical  Assistant. 

sterile  towel,  or  of  a  piece  of  unbleached  muslin  or  of  several 
thicknesses  of  gauze,  about  two  feet  long  and  one  foot  wide, 
torn  lengthwise  half  way  into  two  or  three  tails.  The  two- 
tailed  retractor  is  to  be  prepared  for  an  amputation  through 
the  arm  or  thigh ;  while  for  an  amputation  through  the  fore- 
arm or  leg  a  three-tailed  retractor  will  be  needed,  the  middle 
(narrow)  tail  passing  through  the  interosseous  space.  After 
the  retractor  is  split  it  should  be  rolled  up  until  wanted. 

Position  of  the  Patient.  When  the  amputation  is  through 
the  upper  extremity,  the  limb  should  be  supported  by  a 
nurse  or  assistant  at  right  angles  to  the  body, — the  axilla  or 
the  upper  portion  of  the  arm,  according  as  the  amputation 
is  in  the  arm  or  forearm,  being  at  the  edge  of  the  table.  For 
amputations  below  the  wrist,  as  for  other  operations  on  the 
hand,  the  assistant  may  support  the  extremity  upon  a  board 
placed  at  right  angles  to  the  table  and  held  in  position  by 
the  weight  of  the  patient's  chest  upon  it. 

For  an  amputation  through  the  thigh  or  leg,  the  patient 
should  be  brought  to  the  foot  of  the  table  so  that  more  or 
less  of  the  extremity,  as  the  line  of  division  indicates,  pro- 
jects beyond, — the  opposite  limb  being  supported  upon 
a  chair  and  covered  with  a  sheet,  as  shown  in  figure  112. 

Preparation  of  the  Field.  If  the  tissues  to  be  removed  are 
infected,  they  should  be  freely  covered  with  gauze  or  towels, 
secured  by  a  bandage,  before  any  cleansing  of  the  skin  is 
attempted.  In  any  case  towels  should  be  bandaged  about  the 
distal  portion  of  the  extremity  up  to  a  point  six  inches  below 
the  line  of  amputation.  While  the  hand  or  foot  is  supported, 
the  skin  is  then  thoroughly  disinfected.  The  assistant,  hav- 
ing again  disinfected  his  own  hands,  bandages  fresh  towels 
over  the  distal  portion,  and  gives  the  extremity  into  the 
hands  of  a  nurse  who  is  "  washed  up,"  to  hold  for  a  few 
minutes  in  a  vertical  position  in  order  to  partially  empty 
it  of  blood.  This  process  may  be  much  aided  by  "  milking  " 
the  limb  from  the  digits  towards  the  trunk. 

When  it  is  important  to  save  to  the  patient  as  much  blood 
as  possible,  the  assistant  should  apply  a  rubber  bandage 
firmly  to  the  elevated  limb  from  the  digits  up  as  far  as  de- 


Amputations. 


289 


sired  (figure  109).  The  turns  of  this  bandage  should  not 
reverse,  nor  scarcely  overlap.  The  last  few  turns  are  made 
one  directly  over  the  other,  and  under  the  last  turn  the  body 
of  the  bandage  is  slipped.  The  rest  of  the  bandage  is  then 
unwound  from  the  limb. 

While  the  extremity  is  still  elevated,  the  constrictor  is 
next  to  be  applied,  either  by  the  surgeon  or  by  the  assistant 
himself.  If  a  rubber  bandage  has  been  used  as  above  de- 
scribed, an  Esmarch  band  is  carried  twice  about  the  limb 
close  above  it  and  well  on  the  stretch,  and  is  secured  by  slip- 


FlG.  109.    Driving  blood  from  the  limb  witli  rubber  bandage. 


ping  the  hook  into  a  link  of  the  chain  ;  after  which  the  band- 
age is  removed.  When  a  rubber  bandage  is  used  as  the  con- 
strictor, several  turns  are  made  one  directly  over  the  other, 
and  with  the  rubber  well  stretched ;  the  body  of  the  bandage 
is  slipped  under  the  last  turn,  the  assistant  taking  care  to  re- 
member whether  it  is  inserted  from  below  or  from  above,  in 
order  that  it  may  easily  be  removed  afterwards.  In  con- 
stricting the  upper  extremity,  it  is  important  that  the  band- 


290 


The  Surgical  Assistant. 


age  should  not  be  wound  about  the  centre  of  the  arm,  for  at 
that  level  it  may  cause  paralysis  of  the  musculo-spiral  nerve 
by  pressure  against  the  humerus.  Tubing  used  upon  the 
thigh  or  upper  arm,  in  the  same  manner  as  the  Esmarch 
tourniquet,  is  wound  about  twice,  and  its  ends  are  held 
tightly  on  the  stretch  and  somewhat  away  from  the  body, 
while  an  assistant  secures  them  by  tying  a  piece  of  bandage 
around  the  crossing.  The  application  of  the  older  tour- 
niquets needs  no  further  description  here  than  to  say  that 
they  are  intended  to  press  directly  and  especially  upon  the 
main  bloodvessels   of   the   extremity.     The   constrictor   in 


Fig.  110.    Martin's  rubber  bandage  applied  to  arm. 

place,   the  limb  is  lowered  gently  to  the  horizontal,  and 
towels  are  spread  about  the  upper  end. 

The  Operation.  If  there  are  two  other  helpers  present,  the 
assistant  places  himself  opposite  to  the  operator,  who 
usually  elects  to  stand  so  that  his  left  side  is  towards  the 
patient's  trunk.  If  only  a  nurse  is  present  to  steady  the  distal 
portion  of  the  extremity,  the  assistant  manages  the  proximal 
portion,  standing  on  the  outer  side  of  the  thigh  for  an  ampu- 
tation of  the  lower  extremity,  on  the  side  of  the  arm  opposite 
to  the  operator  for  an  amputation  of  the  upper  extremity. 
If  no  nurse  be  at  hand  the  assistant  must  steady  the  limb 
alone  by  its  distal  or  proximal  portion,  according  as  the 
amputation  is  above  or  below  the  mid  joint.    For  amputations 


Amputations.  291 

at  or  below  the  wrist  or  ankle,  the  nurse  manages  the  limb, 
while  the  assistant  faces  the  operator. 

Grasped  firmly  by  the  assistant  above  and  by  the  nurse 
below,  the  limb  is  abducted  sufficiently  to  allow  the  surgeon 
ample  space,  and  is  steadied  at  first  horizontally,  and  later 
is  depressed  or  elevated  according  as  the  tissues  anterior,  or 
those  posterior,  to  the  bone  are  being  divided. 

For  a  circular  amputation,  or  an  amputation  with  flaps  cut 
by  transfixion,  the  amputating  knife  is  first  provided;  but  in 


Fig.  111.    Application  of  constrictor  to  thigh,  and  method  of  securing  it 
with  strip  of  bandage. 

other  cases  the  surgeon  may  desire  to  mark  out  the  skin 
flaps  with  a  scalpel  before  using  the  amputating  knife.  Ac- 
cording as  he  has  one  or  two  hands  to  spare,  the  assistant 
now  provides  himself  with  one  or  two  sharp-pronged  retract- 
ors with  which  to  lift  up  the  skin-  or  skin  and  muscle-flaps 
to  expose  the  tissues  beneath,  first  at  one  place  and  then  at 
another.  This  is  especially  necessary  when  the  skin  cuff  is  to 
be  dissected  up  in  circular  amputations.    Where,  by  reason 


292 


The  Surgical  Assistant. 


of  the  absence  of  a  second  helper  (to  hold  the  extremity), 
the  assistant  can  spare  but  one  hand  for  retracting,  a  retrac- 
tor should  also  be  given  to  the  surgeon  himself. 

The  muscles  divided  down  to  the  bone,  the  surgeon  is 
now  relieved  of  the  amputating  knife  and  provided  with  the 
catlin  for  severing  the  interosseous  tissues  (amputation 
through  the  leg  or  forearm),  and  then  a  scalpel  to  circumcise 
the  periosteum  and  [a  raspatory  and]  an  elevator  with  which 
to  push  that  tissue  back. 

The  two-tailed  or  three-tailed  retractor  being  next  applied, 
the  assistant  holds  it  drawn  tightly  over  the  proximal  seg- 


FlG.  112.  Position  of  lower  extremities  in  amputation  of  the  thigh.  Con- 
strictor tied. 

ment  of  the  extremity  in  order  to  expose  the  bone  to  the 
saw   (figure   113). 

The  assistant  at  one  end,  and  the  nurse  at  the  other,  must 
be  careful  during  the  sawing  to  hold  the  limb  very  steady, 
for  uneven  pressure  upward  may  fracture  the  bone  before  it 
is  entirely  cut  through,  while  pressure  downward  will  make 
it  bind  upon  the  saw. 

In  order  that  the  sawing  may  be  easy,  the  assistant  should 
drip  water  from  an  irrigator  or  a  sponge  upon  the  bone  until 


Amputations. 


293 


it  is  completely  divided.  Occasionally,  when  the  Gigli  wire 
saw  is  used,  the  operator  requests  the  assistant  to  take 
one  of  the  handles.  In  that  case  he  need  only  bear  in  mind 
that  the  saw  must  not  be  bent  acutely  over  the  bone,  but 


Fig.  113.  Bone  exposed  for  sawing.  Two-tailed  cloth  retractor  drawn 
tightly  on  tissues  above. 

should  be  kept  almost  straight,  for  otherwise  it  is  apt  to  bind 
or  even  break.  If  any  fragment  of  bone  project  beyond 
the  sawn  surface,  the  bone  forceps  will  be  needed  for  its 
removal. 

[When  the  amputation  is  by  the  osteoplastic  method  of 
Bier  there  will  be  needed  a  metacarpal  or  scroll  saw,  or  Gigli 
wire  saw  in  a  scroll  saw  frame,  with  which  to  cut  out  the 
bone  flap,  and  a  few  catgut  stitches  to  secure  its  periosteal 
covering  in  place.] 

The  cloth  retractors  are  now  to  be  removed  and  the  stump 
elevated  so  that  the  operator  can  seek  the  severed  blood- 
vessels, to  facilitate  which  over-hanging  skin  or  muscle 
should  be  drawn  away  with  sharp  retractors.  The  larger 
vessels  having  been  clamped  with  hemostats,  the  assistant 


294 


The  Surgical  Assistant. 


squeezes  the  stump  so  that  the  trickling  of  blood  from  the 
smaller  vessels  may  indicate  their  location.  Until  these  are 
secured  blood  should  not  be  sponged  from  the  cut  surface. 
After  the  bloodvessels  have  been  tied,  forceps  and  scissors 
are  handed  to  the  operator  to  draw  out  and  cut  short  the 
large  nerve  trunks. 

The  constrictor  is  now  to  be  removed,  by  either  the  as- 


FiG.  114.    Stump  supported  and  bloodvessels  exposed  for  clamping. 


sistant  or  the  nurse,  as  expediency  may  dictate.  If  the  rub- 
ber tube  constrictor  has  been  used  it  is  released  by  drawing 
tightly  upon  its  free  ends  and  cutting  through  the  bandage 


Ampjjtations.  295 

knot  carefully  with  a  knife.  The  pressure  on  the  limb  is 
diminished  only  gradually  at  first,  so  that  any  now  bleeding 
large  vessel  can  be  secured,  and  then  the  tourniquet  is  re- 
moved altogether.  After  handling  the  constrictor  the  as- 
sistant should  "  wash  up "  before  again  helping  at  the 
wound. 

When  all  visible  vessels  have  been  tied,  a  handful  of 
sponges,  wrung  out  of  hot  solution,  should  be  laid  upon  the 
cut  surface  to  check  capillary  oozing;  while  for  bleeding 
from  the  bone  itself  a  bit  of  Horsley's  wax  may  be  needed. 

If  the  operator  elects  to  stitch  the  muscles  together  over 
the  bone  there  should  be  handed  him  a  continuous  suture  of 
chromicized  gut  and  a  small  drain  consisting  of  a  narrow 
wick  of  rubber  tissue.  Where,  however,  the  skin  only  is  to 
be  united  a  fenestrated  rubber  drain  should  be  provided,  its 
projecting  end  to  be  transfixed  with  a  safety  pin.  To  unite 
the  skin  there  will  be  needed  plain  or  button  sutures  of  silk 
or  of  silkworm-gut  or  strips  of  sterile  adhesive  plaster. 

The  Dressing  consists  of  [a  strip  of  gutta-percha  over  the 
wound,  and  on  this]  a  com.press  of  gauze,  split  to  surround 
the  tube,  over  which  is  arranged  an  abundance  of  loose 
gauze.  A  few  gauze  compresses  are  spread  evenly  over 
the  loose  pieces,  and  all  are  held  in  place  by  ample  bandag- 
ing. If  the  leg  or  forearm  has  been  amputated,  the  limb 
should  be  supported  upon  a  well-padded  splint  in  order  to 
keep  the  knee  or  elbow,  respectively,  in  extension.  Bony 
prominences,  e.  g.,  the  knee,  shoulder,  iliac  spines,  etc., 
must  be  protected  with  cotton  wool  before  bandaging  over 
them.  The  stump  should  be  held  up  while  the  patient  is 
being  carried  to  bed,  and  is  then  to  be  kept  elevated  by  sup- 
porting it  upon  a  pillow  to  which  it  may  be  pinned  or  band- 
aged. 

Amputation  of  a  Digit.  Here  are  needed,  for  an  "  am- 
putation in  contiguity"  (disarticulation):  scalpel;  mouse- 
tooth  forceps ;  straight  and  curved  scissors ;  two  small  sharp 
retractors;  probe;  [sharp  spoon];  [bone-seizing  ("lion 
jaw  ")  forceps]  ;  two  hemostats;  and  suturing  implements: 
while  for  an  "  amputation  in  continuity  "   (through  a  pha- 


296 


The  Surgical  Assistant, 


lanx)  there  are  also  needed  a  metacarpal  or  scroll  saw  and 
bone-cutting  forceps. 

If  the  amputation  is  at  or  close  to  the  metacarpo-phalan- 
geal  or  metatarso-phalangeal  articulation  a  Martin  rubber 
bandage  should  be  applied  to  the  forearm  or  leg,  respec- 
tively.    For  an  amputation  beyond  that  point  a  piece  of  nar- . 
row  soft  rubber  tubing  or  solid  rubber  may  be  used  as  a 


Fig.  115.    Preparation  of  a  finger  for  amputation. 

constrictor  about  the  base  of  the  digit,  being  secured  at  its 
point  of  crossing  with  an  artery  forceps. 

To  isolate  the  field  of  operation  the  digit  may  be  thrust 
through  a  small  opening  in  a  towel  or  compress  of  gauze. 
If  the  segment  to  be  ablated  is  gangrenous  or  infected  it 
should  be  wrapped  in,  or  held  in,  a  piece  of  gauze. 


OSTEOTOMY   FOR  OSTEOMYELITIS. 

The  instruments  needed  are :  scalpels ;  mouse-tooth  and 
anatomical  forceps ;  straight  and  curved  scissors ;  probe ; 
sharp  retractors;  periosteal  elevator    (appendix,  fag.  77); 


Osteotomy  for  Osteomyelitis. 


297 


raspatory ;  dressing  forceps ;  "  sequestrum  forceps  "  ;  hem- 
ostats ;  small  sponge  carriers ;  chisels  and  gouges ;  mallet ; 
rongeurs;  Volkmann  bone  curettes  (sharp  spoons,  appendix, 
fig.  lo)  ;  [bone  drill  (appendix,  fig.  76)]  ;  suturing  imple- 
ments ;  catgut  sutures ;  a  few  ligatures.  Bits  of  sea-sponge ; 
a  constrictor;  an  irrigator;  and  splints  should  also  be 
ready. 

The  constrictor  is  applied,  as  for  an  amputation.  Instru- 
ments are  handed  in  the  following  order :  scalpel,  mouse- 
tooth  forceps,  sharp  retractors,  periosteal  elevator  or  raspa- 
tory, chisel  and  mallet  (see  figures  38  and  39)  and  then,  as 


Fig.  116.    Removing  chips  of  bone  and  sponging  pus,  etc.,  in  operation  for 
osteomyelitis. 


the  case  requires,  gouges,  curettes,  sequestrum  forceps,  ron- 
geurs or  bone  drill.  The  assistant's  further  duties  consist 
chiefly  in  exposing  the  bone  by  retraction  of  the  divided  soft 
parts  and,  later,  in  keeping  the  bone  cavity  clear.  For  the 
latter  purpose  he  should  hold  in  one  hand  a  dressing  forceps 
to  separate  and  remove  each  bone  fragment  as  it  is  cut  with 
the  chisel,  while  with  the  other  hand  he  mops  out  the  cavity 
with  small  or  large  pieces  of  sponge,  as  described  for  mas- 


298  The  Surgical  Assistant. 

toid  operations.     When  the  osteotomy  is  completed  the  bone 
is  washed  out  with  sublimate  solution,  i-iooo. 

If  the  wound  is  left  open  the  assistant  provides  gauze 
packings  and  an  abundant  absorbent  dressing,  [splint]  and 
bandages.  If  a  bone  flap  has  been  made  (osteoplastic 
method),  a  gauze  drain  is  needed,  and  sutures  [for  the 
periosteum  and]  for  the  skin ;  while  if  the  cavity  is  allowed 
to  fill  up  with  blood,  to  be  organized  into  bone  (Schede 
method),  no  drain  is  used,  but  sutures  are  needed  for  the 
skin  and  a  piece  of  rubber  tissue  is  to  be  laid  over  the  wound. 
Gauze  compresses  are  then  applied  smoothly  from  the  digits 
up,  to  be  held  by  an  even  bandage.  A  starch  bandage  in 
which  are  incorporated  strips  of  basswood  veneer  may  be 
applied  over  all  in  place  of  using  a  posterior  splint.  The 
neighboring  joints  are  to  be  immobilized  in  the  dressing. 
The  constrictor  is  not  removed  until  the  dressing  is  com- 
pleted. 


CHAPTER  XXV. 

SKIN-GRAFTING.     SALINE  INFUSIONS. 

SKIN-GRAFTING    (THIERSCH    METHOD). 

The  following  are  needed:  sharp  (Volkmann)  spoon; 
[McBurney  skin-graft  retractors]  ;  skin-graft  razor  (for 
which  an  ordinary  broad  razor  or  microtome  blade  may  be 
substituted)  ;  two  small  probes;  straight  scissors;  [scalpel]; 
anatomical  forceps ;  rubber  tissue ;  strips  of  rubber  tissue, 
^  to  f  inch  wide,  cut  from  the  sheet  after  it  has  been  dis- 
infected and  thoroughly  rinsed  in  0.9  per  cent.*  salt  solution  ; 
three  basins  of  "  physiologic  salt  solution,"  for  the  rubber 
strips,  the  sponges  and  dressing,  and  the  surgeons'  hands, 
respectively ;  flat  gauze  compresses  of  appropriate  size ; 
gauze-,  cotton-  or  sea-sponges ;  absorbent  cotton ;  and  band- 
ages. 

For  the  success  of  the  graft  it  is  important  that  strict  asep- 
sis should  be  employed,  and  yet  that  no  antiseptic  should 
come  in  contact  with  the  wound  or  the  surface  from  which 
the  epithelium  is  taken,  after  their  preliminary  cleansing. 

It  is  therefore  necessary  that  the  operating  fields,  the  sur- 
geon's and  assistant's  hands,  the  basins,  gutta-percha  strips 
and  the  sea-sponges  (if  these  are  used)  should  all  be  washed 
with  "  physiologic  salt  solution."  This  is  to  be  made  by 
adding  sixty-nine  grains  (very  roughly  a  scant  teaspoon- 
ful  *)  of  table  salt  or,  preferably,  of  chemically  pure  sodium 
chlorid,  to  each  pint  needed  of  tepid  sterilized  water.  The 
solution  should  be  made  in  a  pitcher  or  basin  that  has  been 
disinfected  and  then  washed  out  with  sterile  water. 

After  "  boiling "  all  the  instruments,  except  the  razor, 
they  should  be  rinsed  in  water  and  wiped  dry.  The  razor 
should  be  washed  with  antiseptic  soap,  then  with  alcohol, 
dipped  for  a  few  seconds  in  the  boiling  soda  solution,  rinsed 

*  See  foot-note  under  "  Intravenous  Infusion." 
299 


300 


The  Surgical  Assistant. 


in  sterile  water  and  dried.  "  Boiling  "  is  too  apt  to  dull  the 
edge  of  such  an  instrument  and.  moreover,  it  would  warp 
the  handle  of  an  ordinary  razor,  if  that  be  used. 

The  wound  to  be  treated,  and  the  surface  of  the  thigh 
or  other  part  from  which  the  grafts  are  to  be  taken,  usually 
disinfected  and  dressed  the  day  before,  are  to  be  uncovered 
and  washed  off  with  salt  solution.  The  thigh  is  then  covered 
with  a  towel  wet  in  the  solution,  while  the  wound  is  being 


Fig.  117.    Skin-grafting.     Stretching  the  skin  with  McBurney's  hooks. 

prepared  to  receive  the  grafts.  For  this  there  is  handed 
first  the  spoon  with  which  to  curette  the  exuberant  granula- 
tions usually  present.  The  scalpel  is  also  needed  sometimes 
to  pare  unhealthy  wound  edges.  The  assistant  then  washes 
the  bleeding  surface  with  salt  solution  and  applies  a  dry 
compress  to  check  oozing  while  the  grafts  are  being  shaved. 


Fig.  118.    Skin-grafting.    Stretching  the  skin  with  the  hands. 

The  skin-furnishing  surface  is  now  uncovered  again  and 
the  surgeon  is  provided  with  the  razor  and  a  probe.  The 
skin  is  put  upon  the  stretch  in  a  longitudinal  direction.  This 
is  done  by  using  the  McBurney  retractors  as  shown  in  fig- 
ure 117,  or  by  the  pressure  of  two  sticks  of  wood,  or  by  the 
hands  alone  applied  as  shown  in  figure  118, 


Skin-grafting.     Intravenous  Infusion.  301 

The  stretching  may  be  done  by  the  assistant  alone,  or 
by  the  surgeon  below  and  the  assistant  above.  A  strip  of 
skin  about  two  inches  wide  is  thus  kept  evenly  and  tightly 
stretched  and,  by  the  proper  application  of  the  retractors  or 
the  hands,  somewhat  elevated  above  the  skin  on  each  side 
of  it.  As  the  razor  is  moved  along  the  assistant  should 
drip  salt  solution  upon  it  from  a  sponge,  enough  to  flood  the 
surface  of  the  blade  without,  however,  washing  off  the  epi- 
thelial strip  gathering  upon  it.  Usually  the  surgeon  trans- 
fers each  strip  to  the  wound  as  soon  as  it  is  cut.  The  as- 
sistant removes  the  compress,  gently  dries  the  surface  and 
then,  with  a  second  probe,  assists  the  operator  in  spreading 
the  grafts  evenly  on  the  wound.  When  all  are  in  place  the 
pieces  of  rubber  tissue  are  needed.  These  the  assistant  lifts 
from  their  basin  with  thumb  forceps,  cuts  them  of  appro- 
priate length  (usually  the  width  of  the  wound)  and  hands 
them  one  by  one  in  the  forceps.  The  grafts  covered  with  the 
gutta-percha,  there  are  supplied  compresses  of  gauze  moist- 
ened in  salt  solution,  then  rubber  tissue  again,  or  oiled  silk, 
[absorbent  cotton],  and  a  bandage.  Gutta-percha  strips 
and  moist  compresses  are  similarly  prepared  to  dress  the 
surface  from  which  the  grafts  were  shaved. 

Instead  of  these  rubber  tissue  strips,  Cargile  membrane — 
sterilized  "  gold-beater's  skin,"  sold  dry  in  sterile  envelopes 
—is  sometimes  used  in  the  same  way,  and  silver  foil  has  also 
been  suggested.  Since  all  of  these  macerate  the  underlying 
epithelium  some  surgeons  apply  a  dry  dressing  directly  over 
the  grafts ;  for  this  the  assistant  hands  first  a  single  layer  of 
gauze,  and  then  gauze  compresses  and  a  bandage. 

INTRAVENOUS    INFUSION. 

The  assistant  may  be  called  upon  to  administer  an  intra- 
venous saline  infusion  hiinself,  while  an  operation  is  in  pro- 
gress, and  the  technic  will,  therefore,  be  described  in  detail. 

In  hospitals,  where  emergencies  are  frequent  and  shock 
or  severe  hemorrhage  has  often  to  be  dealt  with,  the  arma- 
mentarium for  this  procedure  should  be  always  at  hand  and 
ready  for  use.     A  box,  divided  into  one  large  and  three 


302  The  Surgical  Assistant. 

small  compartments,  may  be  employed  for  the  purpose* :  In 
the  large  compartment  are  kept,  all  sterilized  and  rolled  in 
sterile  gauze  within  a  sterile  towel :  one  sharp  scalpel 
WTapped  in  cotton ;  one  pair  of  straight  scissors ;  one  pair  of 
curved  scissors ;  bandage  scissors ;  one  anatomical  forceps ; 
one  mouse-tooth  forceps ;  one  pair  of  small  sharp  retractors ; 
two  artery  forceps ;  one  metal  infusion  canula,  with  rubber 
tube  and  glass  attachment  tip;  one  needle  holder;  two  sur- 
gical needles.  The  three  small  compartments  hold,  re- 
spectively :  a  small  jar  containing,  in  alcohol,  a  reel  of  med- 
ium sized  (No.  2)  catgut;  a  jar  containing  several  pads  of 
iodoformized  gauze ;  a  sterilized  two-inch  bandage,  wrapped 
in  sterile  gauze.  Pasted  inside  the  cover  of  the  box  should 
be  a  list  of  the  above-mentioned  contents  with  directions  to 
the  nurse  for  their  resterilization,  replacement  and  replenish- 
ment. In  each  ward  should  be  kept,  strictly  for  this  pur- 
pose, a  graduated  five-pint  infusion  (irrigating)  bottle  and 
attached  tubing ;  a  glass  funnel ;  [a  glass  graduate]  ;  and  a 
bath  thermometer — all  covered,  and  not  only  aseptic  but 
scrupulously  clean  ;  and,  if  hot  sterile  water  is  not  on  tap, 
a  demijohn  of  distilled  water  and  a  special  kettle  in  which 
to  heat  it.  The  other  articles  needed  are :  the  packages  or 
tablets  of  sodium  chlorid  (c.  p.)  ;  a  piece  of  rubber  sheeting; 
a  few  sterilized  towels ;  several  cotton  sponges ;  sublimate 
solution;  and  soap,  brush,  water,  and  ether. 

Not  all  of  the  items  just  listed  are  essential  and,  indeed, 
in  the  emergencies  of  private  practice  an  intravenous  infu- 
sion may  be  safely  administered  with  no  other  paraphernalia 
than  a  torn  handkerchief  tourniquet ;  a  pair  of  scissors ;  a 
strand  of  spool  cotton ;  a  fountain  syringe ;  a  glass  irrigating 
tip  or  stout  aspirating  needle  to  serve  as  a  canula ;  filtered, 
boiled  tap  water ;  table  salt ;  a  teaspoon ;  and  a  clean  hand- 
kerchief to  bind  upon  the  wound.  The  fountain  syringe 
and  tubing  should  be  zvashed  out  and  then  boiled  for  as  many 
of  fifteen  minutes  as  the  urgency  of  the  case  will  allow.  The 
glass  infusion  bottle  possesses  the  advantages  over  the  rub- 
ber bag  that  it  allows  one  to  note  the  rate  of  flow  of  the 

*  Brickner,  Mt.  Sinai  Hospital  Reports — Vol.  I. 


Intravenous  Infusion. 


303 


solution  and  to  determine,  also,  that  no  shred  of  cotton  or 
other  foreign  substance  be  floating  in  it.  This  last,  of  course, 
is  very  important  and,  too,  it  is  important  that  the  lumen  of 
the  tubing  and  of  the  canula  should  harbor  no  particles  of 
rust  or  other  embolus-making  accumulation.  Lacking  both 
bottle  and  fountain  syringe  the  solution  may  be  introduced, 
through  a  funnel  and  tubing,  from  a  pitcher,  the  funnel  be- 
ing kept  continuously  full  to  prevent  the  admission  of  air 
into  the  vein. 

The  solution  is  made  by  filtering  into  the  bag  or  bottle, 


Fig.  119.    Intravenous  infusion. 

through  several  thicknesses  of  sterilized  gauze,  plain  water 
boiled  and  cooled  to  about  iio°  F.,  or  cold  sterile  water 
heated  to  that  temperature,  in  which  after  the  boiling  or 
heating  there  has  been  dissolved  sodium  chlorid  (sterilized 
by  baking  in  an  oven,  or  by  boiling  in  a  few  ounces  of  water) 


304  The  Surgical  Assistant. 

in  the  proportion  of  nine  grammes  to  each  liter  (69  grains 
to  each  pint.*)  The  reservoir  should  be  hung  about  two 
feet  above  the  level  of  the  patient. 

While  the  solution  is  being  thus  prepared  the  operator  dis- 
infects the  skin  with  soap  and  water,  ether,  and  sublimate 

*  This  yields  a  0.9  per  cent,  solution  ("  normal,"  or  better  called 
"  physiologic  "  saline  solution).  The  most  recent  physiologic  teach- 
ing is  that  the  proportion  of  sodium  chlorid  in  the  blood  is  not,  as 
formerly  held,  0.6  per  cent.,  but  0.84  per  cent.  A  0.9  per  cent,  solu- 
tion of  sodium  chlorid  has  the  same  freezing  point  as  blood,  and 
therefore  the  same  osmotic  pressure.  "  The  difference  between  .84 
and  .9  per  cent,  probably  represents  the  amount  contributed  to  the 
osmotic  effect  by  the  many  other  compounds  of  the  plasma." 
(Mathews — Annals  of  Surgery,   August,  1904.) 

A  scant  teaspoonful  of  table  salt  is,  roughly  speaking,  the  quan- 
tity for  each  pint  of  solution.  Such  a  means  of  measuring,  however, 
is  inaccurate  and  is  therefore  justified  only  in  an  emergency.  Prop- 
erly, the  solution  should  be  made  from  a  concentrated  stock  solution 
or  from  chemically  pure  sodium  chlorid  sterilized  in  packages  of 
exact  weight  (69  grains,  138  grains,  etc.).  Infusion  salt  tablets, 
manufactured  for  this  purpose,  are  very  convenient,  but  it  must  be 
remembered  that  often  the  directions  given  with  them  are  for  a  0.6 
per  cent,  solution.  A  tablet  of  30  grains  (2  grams)  yields  a  solution 
of  approximately  0.9  per  cent,  strength  when  dissolved  in  %  vii  (210 
c.c.) 

Although  sodium  chlorid,  the  most  abundant  of  the  inorganic  salts 
of  the  blood,  is  the  only  one  absolutely  essential  to  the  solution, 
Mathews  and  others  have  pointed  out  that  it  is  not  a  matter  of  in- 
difference whether  or  not  the  other  blood  salts  are  represented, 
especially  in  cases  of  toxemia,  etc.,  where  the  infusion  is  repeated 
at  intervals.  Mathews  gives,  as  the  formula  for  a  "balanced" 
physiologic  solution:  sodium  chlorid,  .9  ;  potassium  chlorid,  .03;  cal- 
cium chlorid,  .02;  water,  100.  Tablets  containing  various  combina- 
tions of  the  blood  salts  are  made  by  manufacturing  chemists,  in 
addition  to  the  plain  sodium  chlorid  tablet,  e.  g..  Sharp  &  Dohme 
infusion  tablet  No.  2:  sodium  chlorid,  2.25  grams;  potassium  chlorid, 
0.075  gram;  calcium  chlorid,  0.025  gram;  JohnWyeth  &  Co.  infusion 
tablet  No.  3;  sodium  chlorid,  2.0  grams;  sodium  carbonate,  0.3  gram 
(for  "alkaline"  infusion);  Parke,  Davis  &  Co.  tablet:  sodium  chlo- 
rid, 9.0  grams;  calcium  chlorid,  0.25  gram;  potassium  chlorid,  o.i 
gram. 


Intravenous  Infusion. 


305 


solution,  a  piece  of  rubber  sheeting  or  oilcloth  being  placed 
under  the  extremity  to  protect  the  bed  or  table.     The  veins 


Fig.  120.    Intravenous  infusion.    Opening  the  vein. 


in  the  cubital  fossa  accommodate  themselves  best  to  the  oper- 
ation and  the  median  basilic  vein  is  usually  chosen,  but  any 
superficial  vein,  e.  g.,  one  of  the  sapheni,  may  be  used. 

After  disinfecting  his  hands  the  operator  makes  three  or 
four  turns  of  the  bandage  about  the  upper  arm,  sufficiently 


306 


The  Surgical  Assistant. 


tight  to  constrict  the  veins.  Towels  are  then  spread  about 
the  field.  An  incision  about  an  inch  long  is  made  along  and 
directly  over  the  most  prominent  vein  in  the  cubital  fossa, 
and  v^ith  scalpel  and  forceps  the  vessel  is  freed  from  the 
connective  tissue  on  each  side.  The  handle  of  the  scalpel  is 
thrust  under  it  to  separate  it  from  its  bed  along  the  extent 
of  the  wound.     With  forceps  or  ligature  carrier  a  loop  of 


Fig.  121.    Intravenous  infusion.    Introducing  the  canula. 


catgut  is  then  drawn  beneath  the  vein  and  cut  in  two.  One 
strand  of  gut  is  tied  tightly  about  the  distal  end  of  the 
exposed  vein  segment  and  the  other  strand  is  loosely  placed 
in  a  single  knot  about  the  proximal  end.  The  upper  sur- 
face of  the  vein  is  next  lifted  with  anatomical  forceps,  and 
with  curved  scissors  an  oblique  opening  is  cut  half  way 
across  the  vein.     The  dissection  and  opening  of  the  vein  are 


Intravenous  Infusion.  307 

ordinarily  easy,  but  if  the  vessel  is  collapsed  or  very  small 
they  may  require  much  delicacy.  Where  the  vessel  is  lost 
to  view  or  mutilated  in  an  effort  to  incise  it,  it  will  usually 
save  time  to  abandon  it  and  seek  an  entrance  through  some 
neighboring  vein.  The  canula  is  now  attached  to  the  tubing 
leading  from  the  reservoir,  and  a  little  of  the  fluid  is  allowed 
to  run  on  the  operator's  hand ;  this  is  both  to  drive  all  air 
out  of  the  tube  and  to  determine  that  the  solution  has  not 
cooled  below  a  proper  temperature.*  The  solution  still  run- 
ning, the  little  flap  formed  in  the  vein  is  raised  and  the  canula 
is  thrust  well  in.  The  single  knot  of  the  loose  ligature  is 
drawn  about  the  vein  and  canula  and,  at  the  same  time,  the 
constricting  bandage  is  cut  through.  The  level  of  the  fluid 
in  the  jar  is  now  noted  in  order  to  observe  the  rate  of  flow, 
which  should  not  be  very  rapid,  and  the  quantity  used. 
Under  no  circumstances  should  the  level  of  the  solution  in 
the  reservoir  be  allowed  to  sink  as  far  as  the  level  of  the 
outlet. 

In  cases  of  shock,  suppression  of  urine,  etc.,  one  to  one 
and  one-half  pints,  occasionally  two  pints,  of  salt  solution  are 
employed  for  an  adult  of  average  weight.  Larger  amounts 
are  apt  to  cause  great  congestion  of  the  viscera.  When  the 
infusion  is  injected  to  supply  loss  of  blood,  however,  the 
quantity  may  be  regulated  in  a  measure  by  the  severity  of 
the  hemorrhage.  The  effect  upon  the  pulse  at  the  opposite 
wrist  should  be  watched. 

As  the  canula  is  being  withdrawn  the  proximal  ligature 
is  tied  firmly  about  the  vein,  which  is  then  divided  between 
the  two  ligatures.  The  little  wound,  left  open  or  closed  with 
a  few  stitches,  is  dressed  with  a  simple  compress  of  gauze. 

In  hospital  practice  the  preparation  for,  and  performance 
of,  an  intravenous  infusion  can  be  accomplished  within  fif- 
teen minutes,  and  even  in  the  home  it  ought  not  to  take  much 
longer.  Occasionally  a  chill  and  an  evanescent  rise  of  tem- 
perature (even  as  high  as  io6°    F.)  follow  the  infusion,  but 

*  Intravenous  infusions  are  employed  at  various  temperatures  up 
to  120''  F.  It  is  open  to  question  whether  there  is  any  advantage  iu 
having  then)  above  the  body  temperature  (98°. 6-100°  F.). 


308 


The  Surgical  Assistant. 


usually  they  are  of  no  evil  significance.  (It  has  been  sug- 
gested that  they  are  the  result  of  a  destruction  of  red  blood 
cells  by  an  infusion  not  physiologically  balanced.) 

SUBCUTANEOUS    SALINE   INFUSION.      (hYPODERMOCLYSIS.) 

The  solution  is  prepared  in  the  same  manner  as  for  intra- 
venous infusion.  The  reservoir  is  hung  about  three  feet 
above  the  patient.  Attached  to  the  tubing  is  a  stout  aspi- 
rating needle  which,  while  the  solution  is  flowing,  is  thrust 


Fig.  122.    Subcutaneous  saline  infusion. 

almost  horizontally  into  the  subcutaneous  tissue  of  the  back 
(loin)  or  the  buttock  or  under  the  female  breast.  The  punc- 
ture wound  must  be  covered  with  a  bit  of  sterile  gauze  or 
with  collodion.  The  latter  will  not  adhere  to  the  skin  if  the 
puncture  hole  is  wet  or  bleeding.  To  obviate  the  difficulty 
the  skin  about  the  tiny  wound  is  pinched  up  tightly  and 
wiped  dry,  the  collodion  dabbed  on,  and  the  compression 
continued  for  a  minute  or  two  thereafter. 


APPENDIX   I. 


APPENDIX    I. 

THE     PRELIMINARY     PREPARATION      AND     ROUTINE 
AFTER-TREATMENT    OF    OPERATIVE    CASES. 

FOR  AN    OPERATION    UNDER    GENERAL    NARCOSIS   TO    BE 
PERFORMED  IN   THE  EARLY  AFTERNOON. 

The  patient  is  allowed  a  light  supper  (e.  g.,  coffee,  toast 
and  one  egg)  the  evening  before.  The  morning  of  the  oper- 
ation a  cup  of  tea  or  coffee  is  allowed  for  breakfast,  but  noth- 
ing thereafter.  In  many  cases,  however,  water  may  be  al- 
lowed until  about  an  hour  preceding  the  operation. 

About  three  or  four  o'clock  of  the  preceding  afternoon 
there  is  administered  an  active  purge,  e.  g.,  pulv.  glycyrr- 
hizae  comp.  §  ss,  or  magnesium  sulphate  ^  ss,  or  a  mixture  of 
pulv.  glyc.  CO.  and  magn.  sulphat.  aa  3  ii,  or  oleum  ricini  §  ss, 
or  hydrarg.  chlorid.  mit.  (e.  g.,  a  series  of  six  one-half  grain 
doses  of  calomel  given  at  ten-minute  intervals).  About  ten 
o'clock  of  the  same  evening  a  high  soapsuds  enema  is 
administered,  and  this  is  repeated  about  six  o'clock  the  next 
morning.  At  ten  o'clock  (four  or  five  hours  after  the 
second  high  injection)  a  low  enema  is  given. 

Just  before  the  purgative  is  administered  [the  patient  is 
given  a  warm  bath  and]  the  field  of  operation  is  carefully 
shaved,  scrubbed  with  soap  and  water  and  covered  with  a 
"  soap  poultice."  This  consists  in  an  abundance  of  loose 
gauze,  wrung  out  in  a  lather  of  green  soap,  covered  with 
rubber  tissue  or  oiled  silk,  and  held  in  place  with  a  bandage. 
When  the  second  high  enema  is  given,  the  soap  poultice  is 
removed,  the  skin  washed  with  alcohol  and  ether,  and  gauze 
wet  in  sublimate  solution,  1-3,000,  applied.  This  dressing  is 
not  removed  until  the  operation. 

After  operation, — Morphin  is  frequently  needed.     Cath- 

311 


312  The  Surgical  Assistant. 

eterization  at  eight-hourly  intervals  may  be  necessary.  All 
nourishment  by  mouth  is  withheld  for  four  to  six  hours  or 
until  vomiting  ceases.  Fluid  diet  is  maintained  until  the 
bowels  are  moved.  This  is  ordinarily  done  on  the  second 
day  after  the  operation  by  means  of  a  high  soapsuds  [and 
peppermint  water]  enema  in  the  morning,  and  a  cathartic 
(pil.  cathartic,  vegetabile  or  pil.  cathartic,  comp.  or  cascara 
sagrada,  etc.)   the  same  evening. 

RECTAL  OPERATIONS   (e.g.,  hemorrhoids). 

The  bowels  are  moved  as  above  but,  in  addition,  low 
enemata  are  repeated  until  the  fluid  returns  clear,  and  a 
rectal  tube  is  inserted  for  half  an  hour  two  hours  before 
the  operation.  The  perineum  is  shaved  and  prepared  as 
above. 

After  operation, — For  two  days  fluid  diet  is  maintained, 
and  the  bowels  are  confined  by  the  administration  of  tinct. 
opii  deod.  lUx  b.i.d.  On  the  morning  of  the  third  day  there 
is  administered  Epsom  salt  §  ss,  followed  in  two  hours  by  an 
injection  of  olive  oil  (through  the  tampon  canula)  and  an 
hour  later  by  a  low  soapsuds  enema.  Thereafter  solid  or 
semi-solid  diet  is  allowed. 

ABDOMINAL    OPERATIONS. 

In  emptying  the  bowels  it  is  best  to  employ  the  additional 
procedures  described  for  rectal  operations.  For  an  opera- 
tion upon  the  female  pelvic  organs  the  vagina  is  also  pre- 
pared (vide  infra).  Stomach  operations. — For  36-48  hours 
preceding  the  operation  the  diet  should  be  only  of  sterilized 
fluids,  and  the  mouth  is  ta  be  kept  clean  by  the  free  use  of 
a  tooth-brush  and  of  an  antiseptic  mouth-wash  (e.  g.,  equal 
parts  of  peroxid  of  hydrogen  and  of  sublimate  solution, 
1-10,000).  An  hour  before  the  operation  gastric  lavage  is 
performed,  preferably  with  sterile  water  or  saline  solution 
and  a  sterile  s-tomach  tube. 

After  operation, — The  time  and  manner  of  moving  the 
bowels  depend,  to  a  great  extent,  upon  the  nature  of  the 
operation  and  the  condition  of  the  patient.    In  the  presence 


Routine  of  Operative  Cases.  313 

of  peritonitis,  the  bov/els  are  moved  in  twenty-four  hours. 
For  tympanites,  an  enema  of  peppermint  water,  to  which 
may  be  added  3  i-ii  of  oil  of  turpentine,  may  be  indicated. 
In  cases  in  which  gauze  drainage  through  the  vagina  is 
employed,  voluntary  urination  is  not  to  be  permitted  until 
the  gauze  is  removed. 

OPERATIONS    UPON    THE    NOSE. 

An  antiseptic  spray  or  douche  is  to  be  used  freely  before- 
hand. 

OPERATIONS  UPON  THE  MOUTH   OR  THROAT. 

Tooth-brush  and  mouth-wash  are  to  be  used  as  for  gastric 
operations. 

BLADDER    OPERATIONS. 

In  addition  to  the  other  preparations,  urinary  disinfect- 
ants (e.g.,  urotropin,  gr.  vii  t.i.d.),  the  free  drinking  of 
water,   [and  bladder  irrigations]   are  employed. 

Preparatory  to  a  cystoscopic  examination  without  general 
narcosis,  an  enema  is  administered  in  the  morning  if  the 
bowels  have  not  moved,  and  half  an  hour  before  the  exami- 
nation an  opium  suppository  is  inserted. 

After  the  passage  of  instruments  through  the  urethra,  the 
administration  of  quinin  (gr.  x)  is  often  desirable  as  a  pre- 
ventive of  "  urethral  chill." 

VAGINAL    OPERATIONS. 

Douches  of  bichlorid  of  mercury,  1-5,000,  are  adminis- 
tered morning  and  evening  before  the  operation,  and  after 
the  last  enema  on  the  day  of  the  operation.  The  external 
genitals  are  shaved  (except  sometimes  for  curettage,  drain- 
age of  pelvic  abscess,  etc.)  and  prepared  by  soap  poultice 
and  sublimate  dressing  as  are  other  fields  of  operation. 

After  operation. 

Curettage,  trachelorrhaphy.  The  vaginal  gauze  is  re- 
moved after  twenty-four  hours ;   the   uterine   gauze   after 


314  The  Surgical  Assistant. 

forty-eight.  The  bowels  are  moved  on  the  second  day,  and 
sublimate  douches,  i-5,cxx)  are  administered  daily  after  all 
gauze  is  out. 

Plastic  operations  (colporrhaphy,  perineorrhaphy).  Un- 
til the  morning  of  the  fourth  day,  the  thighs  are  bound 
together,  fluid  diet  is  maintained,  tinct.  opii  deod.  TTtx  are 
administered  b.i.d.,  and  catheterization  is  performed  every 
five  hours.  On  the  fourth  morning  Epsom  salt  §  ss  is  given, 
followed  in  one  hour  by  an  enema  of  olive  oil  ^  iv^  and  after 
another  hour  by  a  low  soapsuds  enema.  Thereafter  semi- 
solid diet  is  begun,  a  douche  and  an  enema  are  administered 
each  morning,  and  voluntary  urination  is  permitted.  Until 
the  wound  heals,  however,  it  is  to  be  washed  off  and  a  fresh 
gauze  pad  is  to  be  applied,  after  each  urination  and  defeca- 
tion. 

Vaginal  hysterectomy  and  other  operations  in  which  a 
communication  is  made  between  the  vagina  and  the  abdom- 
inal cavity.  Catheterization  is  to  be  performed  at  regular  in- 
tervals until  the  drainage  gauze  is  removed. 

EMERGENCY    CASES. 

To  patients  requiring  operation  before  the  bowels  can  be 
regularly  prepared  a  low  enema  may  be  administered.  In 
the  presence  of  an  intra-abdominal  abscess  (appendicitis, 
etc.),  a  high  enema  is  contra-indicated,  and  the  preparation 
of  the  skin  must  be  conducted  with  great  gentleness. 

THE  PREPARATION  OF   SURGICAL  MATERIALS  ; 
FORMULARY. 

CATGUT. 

Of  the  commercial  gut  only  strands  that  are  clean,  strong, 
rough  and  yellow  should  be  selected. 

Bichlorid  Method,     (v.  Bergmann.) 

(a).       I.  Wind  in  rings  or  on  spools. 

2.  Remove  all  fat  by  immersion  in  commercial  (sul- 
phuric) ether  for  twenty-four  hours  or  longer, 


Preparation  of  Catgut.  315 

changing  the  ether  if  necessary  [or  by  soaking 
in  benzin  for  a  whole  month]. 

3.  Remove  from  ether  and  place  upon  a  towel  to  dry. 

4.  Place  in 

hydrarg.  chlorid.  corrosiv i 

alcohol  95  per  cent 500 

small  sizes  (00  and  o)  for  nine  days,  larger 
sizes  for  fourteen  days. 

5.  Transfer  to  alcohol  95  per  cent.     Preferably  keep 

in  alcohol  two  weeks  before  using. 

(Mt.  Sinai  Hospital,  N.  Y.) 
There  are  various  modifications  of  this  method.     Thus : 
(b).   1,2.  Select  and  wind  gut  and  remove  fat  as  in  (a). 

3.  Pour  off  ether  and  cover  gut  with 

hydrarg.  chlorid.  corrosiv 20 

distilled  water 400 

alcohol    2000 

Renew  this  solution  three  times  at  intervals  of 
twenty-four  hours. 

4.  Soak  for  twenty-four  hours  in  absolute  alcohol. 

5.  Preserve  in  fresh  alcohol. 

(Philadelphia   German   Hospital.) 
(c).   1,2.  As  in  (a). 

3.  Place  in 

hydrarg.  chlorid  corrosiv gr.  xx 

acid,  tartaric gr.  c 

alcohol  95  per  cent §  vi 

smaller  sizes  five  to  seven  minutes,  medium 
sizes  ten  to  fifteen  minutes,  largest  sizes  twenty 
to  thirty  minutes. 

4.  Preserve  in   alcohol  95   per  cent.,  to  each  eight 

ounces  of  which  is  added  one  drop  of  a  solu- 
tion of  palladium  chlorid.  (gr.  xv  to  |  i). 
(Johnston's     quick     method,     employed     at 
Jefferson  Hospital,  Philadelphia.) 
Claudius'  Method* 

The  raw  gut,  without  any  fat-removing  preparation,  is 
*  Deutsche  Zeitschrift  f.  Chirurgie,  Vol.  64,  p.  489. 


316  The  Surgical  Assistant. 

simply  wound  in  single  layers  on  glass  spools  and  dropped 
into  a  solution  of 

iodin   (pulverized) i. 

potassium  iodid i. 

distilled   water lOO 

in  a  well  stoppered  jar,  and  left  there  eight  days.  Before 
using,  the  iodin  may  be  washed  off  by  rinsing  the  spool  in 
an  aseptic  solution,  but  if  the  gut  is  used  directly  from  the 
solution,  it  will  be  more  distinctly  antiseptic  (iodin).  Un- 
used portions  of  gut  are  re-sterilized  by  returning  them  to 
the  same  (or,  better,  another)  jar  of  the  solution  for  from 
half  an  hour  to  eight  days,  according  to  the  contamination 
to  which  they  have  been  exposed.  Catgut  prepared  by  this 
cheap  and  simple  method  is  strong,  smooth,  not  swollen, 
pliable,  knots  easily,  does  not  curl  up  as  does  gut  kept  in 
alcohol,  and  is  absorbed  in  about  the  same  time  as  catgut 
prepared  by  other  methods.  If  it  be  left  in  the  solution 
more  than  three  or  four  months,  however,  it  is  apt  to 
become  too  brittle. 
Elsberg's  Method.* 

1.  Free  the  raw  gut  of  fat  by  immersing  it  for  twenty-four 

to  forty-eight  hours  in  ether  or  in  chloroform,  or  in  a 

mixture  of 

chloroform    i 

ether    2 

2.  Wind   tightly,  in  a  single  layer,  on  large  glass  spools 

having  a  hole  in  each  flange,  in  which  the  ends  of  the 
gut  can  be  tied. 

3.  Boil  for  ten  to  thirty  minutes  in  a  saturated  solution  of 

ammonium  sulphate  in  water,  or  for  three  to  ten 
minutes  in  a  saturated  solution  of  ammonium  sulphate 
in  aqueous  carbolic  acid  solution,  i  per  cent,  to  2  per 
cent. 

4.  Remove  the  spools  with  sterile  forceps,  and  rinse  them 

for  half  to  one  minute  in  warm  sterile  water,  carbolic 
acid,  or  sublimate  solution. 

5.  Use  at  once  or  preserve  in  strong  alcohol. 

*  International  Clinics,  Vol.  i.,  nth  Series. 


Preparation  of  Catgut.  317 

Catgut  can  be  re-sterilized  (from  three  to  six  times)  by 
boiling  again.  The  solution  can  be  used  repeatedly  by 
simply  adding  water  to  replace  that  which  has  evaporated; 
the  ammonium  sulphate  crystallizes  out  unchanged. 

Cumol  Method  (Kronig). 

1.  Remove  all  fat  with  ether,  chloroform  or  benzin. 

2.  Suspend  it,  rolled  in  rings  or  in  figure-of-eight  forms,  in 

a  glass  beaker  or  large  test-tube. 

3.  Heat  in  an  oven  or  over  a  sand-bath  at  80°  C.  for  two 

hours. 

4.  Still  suspended  in  the  beaker,  pour  in  cumol  at  100°  C. 

and  heat  to  or  nearly  to  165°  C,  maintaining  that  tem- 
perature one  hour.  (Cumol  boils  at  a  little  above 
165°  C.) 

5.  Pour  off  cumol  and  dry  in  an  oven  or  over  a  sand-bath 

at  100°  C.  for  two  hours. 

6.  With  sterile  forceps  transfer  to  alcohol. 

This  method  is  complicated,  difficult  and  not  without 
danger,  and  is  not  suitable  for  office  preparation. 

Boiling  in  Alcohol. 

Alcohol  boils  at  174°  F.,  which  temperature  is  not  suffi- 
ciently high  to  sterilize  catgut.  The  alcohol  must,  there- 
fore, be  boiled  under  pressure,  to  accomplish  which  special 
apparatus  is  required. 

(a).  In   an   apparatus   the   fat-freed   gut   is   boiled   fifteen 
minutes  in  a  mixture  of 

liquified   phenol 5 

distilled  water 10 

ethyl  alcohol 85 

(Saul's   Method.) 
(b).  Fat-freed  catgut  is  wound  on  a  glass  spool  and  placed 
in  a  glass  tube.    This  tube  is  nearly  filled  with  alco- 
hol,  its  end  is  hermetically   sealed,   and  it  is  then 
subjected  in  an  autoclave  to  live  steam  at  248°  F. 
for  an  hour. 
When  needed,  the  glass  tube  is  broken  and  the  catgut 
dropped  into  sterile  water  to  soften  it. 


318  The  Surgical  Assistant. 

Formalin  Method. 

(a).  I.  Remove    fat    from    gut   by    ether,    chloroform    or 
benzin. 

2.  Wind  on  glass  plates  in  not  more  than  one  or  two 

layers. 

3.  Soak  for  twelve  to  forty-eight  hours  in  2  per  cent. 

to  4  per  cent,  aqueous  formaldehyd  solution  (1-2 
parts  of  commercial  formalin  in  twenty  parts  of 
distilled  water). 

4.  Remove  formalin  by  soaking  twenty-four  hours  in 

running  water. 

5.  Boil  the  formalin-hardened  gut  in  distilled  water 

fifteen  to  thirty  minutes. 

6.  Preserve  in 

acid  carbolic 4 

or 

hydrarg.  chlorid.  corrosiv i 

glycerin    5 

alcohol  96  per  cent 100 

(Hofmeister's  technic.) 

or  cut  the  catgut  in  pieces,  tie  them  in  bundles 

and  preserve  in  a  glass-stoppered  jar  containing 

pulverized   iodoform 100 

glycerin    $0 

absolute   alcohol 950 

Shake  the  mixture  every  few  days. 

(Senn's  modification  of  Hofmeister's  technic.) 

(b).   I.  Cut  the  raw  gut  into  required  lengths. 

2.  Wrap  each  piece  separately  in  filter-paper  that  has 

been  soaked  for  twenty-four  hours  in  a  2  per 
cent,  solution  of  formaldehyd.  Leave  thus  for 
twenty-four  hours. 

3.  Dry  in  the  paper  at  a  temperature  of  140°  F. 

4.  Preserve  dry  until  needed ;  then  soak  a  few  minutes 

in  9,  sterile  solution. 

(Vollirier-Kossrnan  technic.) 


Preparation  of  Catgut.  319 

( c ) .  (Formol-iodin) . 

1.  Submerge   raw  commercial  catgut   in  4  per  cent. 

aqueous  formalin  solution  thirty-six  to  forty- 
eight  hours. 

2.  Wash  in  running  water  twelve  hours. 

3.  Submerge  in  Claudius'  iodin  solution  (vide  supra) 

eight   days. 

(Stone's  modification  of  Claudius'  method,  to  in- 
crease tensile  strength  of  gut.*) 

Dry  Heat  Method  of  Boeckmann. 

1.  Soak  in  ether  one  week  to  remove  fat. 

2.  Wrap  in  strands  in  fine  tissue-  or  paraffin-paper,  and 

seal  in  paper  envelopes. 

3.  Place  envelopes  in  sterilizer  and  subject  them  for 

three  hours  to  a  dry  heat  of  284°  F.,  and  for  four 
hours  to  290°  F. ;  or  to  300°  F.  for  three  hours  on 
two  successive  days. 

4.  When  needed,  cut  off  end  of  envelope,  remove  inner 

package  with  sterile  forceps,  and  dip  gut  in  sterile 
water  to  make  it  pliable. 

Chromicizing  Catgut. 

(a).  I.  Roll  catgut  on  spools. 

2.  Alcohol  95  per  cent,  for  twenty-four  hours. 

3.  Dry  on  a  towel. 

4.  Place  in 

potass,  bichromat gr.  lxxv 

aqueous  solution  carbolic  acid,  5,^...  5  pints 
small  sizes  for  forty-eight  hours,  large  sizes  for 
fifty-two  hours. 

5.  Alcohol   95   per   cent.,   small   sizes   for   five   days, 

large  sizes  for  three  to  four  weeks, 
(b).  I.  Place  200  parts  by  weight  of  catgut  for  twenty- 
four  to  forty-eight  hours  in 

carbolic  acid 200 

water  2000 

chromic  acid i 

*  Medical  Record,  November  12,  1904. 


320  The  Surgical  Assistant. 

2.  Preserve  in  alcohol. 

(Am.  Text-Book  of  Surgery.) 

(c).  I.  Remove  fat  with  ether. 

2.  Place  for  twenty-four  hours  in  a  4  per  cent,  aque- 

ous solution  of  chromic  acid. 

3.  Dry  in  a  hot-air  sterilizer. 

4.  Sterilize  by  one  of  the  above  methods. 

(d).  Elsberg's  Method. 

Boil  spools  of  catgut  in  i-iooo  aqueous  chromic  acid 
solution  saturated  with  ammonium  sulphate.  Other 
steps  as  for  Elsberg's  method  of  plain  sterilization. 

The  resistance  of  the  catgut  to  absorption  in  the  tissues 
varies  with  the  strength  of,  and  duration  of  exposure  to, 
the  chromicizing  solution. 

KANGAROO   TENDON. 

Kangaroo  tendon  is  prepared  in  much  the  same  manner 
as  chromicized  catgut.    It  should  always  be  chromicized. 

Marcy's  Method. 

1.  Soak  the  dried  tendon  in  sublimate  solution,  1-1,000. 

2.  Separate  the  individual  strands. 

3.  Dry  each  strand  in  a  sterile  towel. 

4.  Chromicize  (vide  supra). 

5.  Keep  in 

carbolic  acid 5 

boiled  linseed  oil 100 

6.  When  needed,  wipe  the  oil  off  of  each  strand  with  a 

sterile  towel  and  immerse  for  half  an  hour  in 
1-1,000  aqueous  solution  of  bichlorid  of  mercury. 
(This  does  not  swell  and  soften  the  tendon  as  it 
would  catgut.) 

Truax'  Method. 

I,  2,  3.  As  in  Marcy's  technic. 

4.  Immerse  in  aqueous  solution  formaldehyd,  2  per 

cent,  to  4  per  cent,  for  forty-eight  hours. 

5.  Wash  in  runningwater  twelve  to  twenty-four  hours. 


Preparation  of  Suture  Materials.  32l 

6.  Immerse  tendons  until  "  dark  golden  brown  "  in  a 
fresh  solution  of 

chromic  acid i 

carbolic  acid 200 

water 4000 

7.  Dry  between  sterile  towels  and  preserve  in  10  per  cent. 

carbolized  oil. 

8.  When  needed,  wipe  off  each  strand  with  a  towel  satu- 

rated with  sublimate  solution,  i-iooo. 

CRANE   AND    HERON    TENDON.* 

May  be  sterilized  by  the  method  of  Claudius  (vide  supra). 

HORSEHAIR, 

1.  Wash  with  water  and  potash  soap. 

2.  Boil  ten  to  fifteen  minutes  in  4  per  cent,  carbonate  of 

sodium  solution. 

3.  Preserve  in  sublimated  alcohol,  i-iooo. 

SILK. 

Wind  on  glass  spools  and  boil  vigorously,  small  sizes  for 
fifteen  minutes,  larger  sizes  for  half  an  hour,  in  5  per  cent, 
carbolic  acid  solution  or  i  per  cent,  carbonate  of  sodium 
solution.  Preserve  in  5  per  cent,  carbolic  acid  solution  or 
in  sublimated  alcohol,  i-iooo. 

CELLULOID   thread. 

English  gray  linen  thread  is  boiled  in  i  per  cent,  solution 
of  carbonate  of  sodium,  then  wrapped  in  a  sterile  towel, 
dried  in  hot  air  or  steam  and,  finally,  is  dipped  in  a  solution 
of  celluloid  heated  in  a  hot-air  sterilizer,  and  is  placed  in  a 
sterile  container. 

*  The  leg  tendons,  11-16  inches  long,  of  grallatorial  birds  are  rec- 
ommended by  Kieffer  (Journal  Am.  Med.  Assoc,  November  19, 
1904),  as  being  readily  procured,  clean,  easily  sterilized,  strong, 
tying  well,  and  resistant  to  absorption  for  about  six  weeks. 


322  The  Surgical  Assistant. 

silkworm-gut. 

(a).  I.  Cut  off  the  rough  ends  of  the  commercial  silkworm 
fibers. 

2.  Boil  in  5  per  cent,  carbolic  acid  solution,  or  in  plain 

water  for  half  an  hour  (never  in  sodium  carbo- 
nate solution). 

3.  Preserve  in  plain  or  sublimated  alcohol,  in  carbolic 

acid  solution  i  per  cent,  to  5  per  cent.,  or  in  lysol 
solution  ^  per  cent. 

(b).  I.  As  in  (a) 

2.  Place  in  ether  for  forty-eight  hours. 

3.  Corrosive  sublimate  solution,  i-iooo,  for  one  hour. 

4.  Preserve  as  in  (a). 

(c).    I.  As  in  (a). 

2.  Soak  fifteen  minutes  in  5  per  cent,  carbolic  acid 

solution. 

3.  Sterilize  by  live  steam. 

4.  As  in  (a). 

Silkworm-gut  is  easily  dyed,  and  incidentally  impregnated 
with  an  antiseptic,  by  immersing  it  for  twenty-four  hours  in 
a  I  per  cent,  solution  of  methyl  violet,  before  it  is  boiled. 

SEA-SPONGES. 

(a).  I.  Select  firm,  well-beaten  sponges. 

2.  Place  for  twelve  hours  in 

commercial  muriatic  acid i 

water  3 

3.  Wash  and  squeeze  out  repeatedly  in  running  water. 

4.  Soak  three  to  four  days  in  5  per  cent,  green  soap 

in  water,  stir,  wash  and  squeeze  out. 

5.  Wash  until  clean  in  running  water. 

6.  Place  in  5  per  cent,  carbolic  acid  solution  at  least 

twenty-four    hours.      Preserve    in    carbolic    acid 
solution.  (Mt.  Sinai  Hospital,  N.Y.) 


Preparation  of  Surgical  Materials.  323 

(b).  I.  Beat  out  dust. 

2.  Place  for  forty-eight  hours  in  15  per  cent,  solution 

muriatic  acid. 

3.  Wash  with  water. 

4.  Place  for  one  hour  in  a  solution  of 

potassium  permanganate 3  iii 

water 5  pints 

5.  Soak  four  hours  in  a  solution  of 

sodium  hyposulphite ^  x 

hydrochloric  acid ^  v 

water 3  pints 

6.  Wash  with  running  water  for  six  hours. 

7.  Preserve  in  sublimate  solution,   i-iooo. 

(From  Da  Costa's  "Modern  Surgery.") 

WAX    OR   PARAFFIN    PAPER. 

(a).  Melt  the  wax  or  paraffin.  While  pouring  it  on  thin 
[tissue]  paper,  iron  evenly  with  a  hot  flatiron. 

(b).  Dip  the  paper  in  melted  wax  or  paraffin,  then  pass  it 
through  a  laundry  mangle. 

RUBBER   TISSUE  (GUTTA-PERCHA). 

Sterilize  by: 

1.  Washing  and  soaking  in  green  soap  and  cold  water. 

2.  Rinsing  in  plain  water. 

3.  Immersing  for  twenty-four  hours  in  sublimate  solution, 

I-IOOO. 

4.  Preserve  in  sterile  water  or  salt  solution,  or  in  a  sterile 

towel. 

RUBBER   TUBING. 

1.  Cut  in  lengths. 

2.  Blow  out  dust. 

3.  Boil  in  plain  water  ten  minutes. 

4.  Dry  on  sterile  towel. 

5.  Keep  in  5  per  cent,  carbolic  acid  solution. 

RUBBER    gloves;    CATHETERS. 

(See  Chapters  V.  and  VII.) 


324  The  Surgical  Assistant. 

murphy's  gutta-percha  solutions, 
Benzin  solution,  4  per  cent,  for  surgeon's  hands ;  acetone 
solution,  4  per  cent,  for  field  of  operation. 

1.  Cut  the  gutta-percha  chips  in  small  pieces. 

2.  Wash  in  formalin,  full  strength,  and  dry. 

3.  Macerate  the  chips  in  benzin  or  acetone  for  three  days, 

then  filter  through  cotton  that  has  been  in  formalin 
vapor  for  forty-eight  hours.  Repeat  filtering  twice, 
and  solution  is  ready  for  use.  The  benzin  is  sterilized 
by  boiling  it  in  a  water-bath  in  a  strong,  well-corked 
bottle.  The  gutta-percha  solution  itself  loses  its  adhe- 
siveness if  boiled,  and  it  is  not  miscible  with  formalin. 
(Method  of  E.  von  Hermann,  chemist.*) 

traumatacin. 

A  saturated  solution  of  gutta-percha  in  chloroform. 

senn's  decalcified  bone  chips. 

1.  Saw  the  shaft  of  the  femur  or  the  tibia  of  a  recently 

killed  ox  into  sections  two  inches  in  length. 

2.  Remove  periosteum  and  marrow,  and  place  the  remain- 

ing segments  for  two  to  four  weeks  into  15  per  cent, 
solution  of  hydrochloric  acid,  changing  the  solution 
daily. 

3.  Wash  decalcified  segments  in  distilled  water. 

4.  Immerse  a  few  minutes  in  dilute  potash  solution  to  neu- 

tralize the  remaining  acid. 

5.  Immerse  in  distilled  water  for  twenty-four  hours. 

6.  Cut  each,  in  direction  of  its  long  axis,  into  strips  three- 

quarters  of  an  inch  wide ;  slice  strips  into  chips  one 
millimeter  thick. 

7.  Preserve  chips  in  sublimated  alcohol,  1-500. 


I.  Mix 


VON    MOSETIG-MOERHOF   BONE-FILLING. 

iodoform   60 

spermaceti 40 

oleum  sesami  40 

*  Murphy,  Journal  A.  M.  A.,  September  17,  1904. 


Preparation  of  Surgical  Materials.  325 

2.  Heat  slowly  to  lOo''  C.  in  a  flask  on  a  water  bath;  keep 

at  that  temperature  fifteen  minutes. 

3.  Allow  to  cool  and  solidify  while  shaking  constantly. 

4.  When  needed,  melt  and  heat  to  50°  C.  in  a  thermostat. 

iiorsley's  boxe  wax. 

1.  Mix 

salicylic  acid i 

almond  oil , i 

beeswax 7 

2.  Boil  ten  minutes. 

3.  Pour  in  shallow  dish  to  cool ;  cover. 

PARAFFIN  for  SUBCUTANEOUS  INJECTION^  ETC. 

Mix  commercial  paraffin  with  sufficient  petroleum  jelly 
to  reduce  melting  point  to  desired  degree,  e.g.,  110°  F., 
as  determined  accurately  with  thermometer.  Proportions 
cannot  be  stated,  for  blocks  of  commercial  paraffin  are  not 
of  the  same  melting  point  throughout.  \Mien  needed,  boil 
the  mixture  in  a  flask  or  tin  receptacle  placed  ia  the  water  in 
a  sterilizer;  cool  in  the  flask  to  about  120°  F. ;  draw  into  ster- 
ile syringe ;  evacuate  air  bubbles  from  syringe  and  place  it  in 
sterile  water  at  So""  F.  to  allow  paraffin  to  cool  in  it  uniformly 
to  semi-solid  state.  Before  injecting,  warm  the  attached 
syringe  needle  in  hot  water. 

(Harmon  Smith's  technic.) 

plaster  bandages. 

The  best  dental  plaster,  kept  in  air-tight  containers,  should 
be  used.  Gauze  or  crinolin,  cut  in  strips  about  five  yards 
long  and  of  the  desired  width,  is  laid  upon  a  table  and  the 
plaster  is  smoothly  and  evenly  rubbed  into  its  meshes.  In 
order  that  the  plaster  will  not  be  spilled  out  of  the  strip,  it 
should  be  rolled  up  little  by  little  as  the  powder  is  incor- 
porated in  it.  The  bandage,  very  loosely  rolled,  is  wrapped 
up  in  waxed  paper  or  gutta-percha,  and  placed  in  a  tin  box, 
the  cover  of  which  is  sealed  around  the  edge  with  a  strip  of 
adhesive  plaster. 


326  The  Surgical  Assistant. 


STARCH   BANDAGES. 

Cheese-cloth  impregnated  with  starch  and  dried  is  cut  into 
strips  of  desired  width  and  rolled  up. 


WATER    GLASS   (SOLUBLE  GLASS)  DRESSING. 

The  wound  is  dressed  and  bandaged  in  the  ordinary  way. 
Into  and  upon  the  bandage  is  applied  with  a  brush  liquor 
sodii  silicatis  (U.  S.  P.)  or  liquor  potassii  silicatis,  or  a  mix- 
ture of  two  parts  of  the  latter  with  one  part  of  the  former. 
(The  combination  is  said  to  set  more  quickly  and  firmly  than 
either  solution  used  alone.) 

Instead  of  painting  on  the  soluble  glass,  the  bandages  may 
be  dipped  into  it  and  then  applied. 

TOWELS,  CAPS   AND   GOWNS. 

1.  Remove  blood,  pus,  etc.,  by  soaking  several  hours  in  cold 

water,  to  which  may  be  added  some  ammonia. 

2.  Rinse  in  several  changes  of  cold  water. 

3.  Boil  in  soap  and  soda  for  about  an  hour. 

4.  Rinse  in  plain  water. 

5.  Dip  in  bluing. 

6.  Wring  out. 

7.  Dry. 

8.  Iron  and  fold ;  wrap  in  a  package  in  a  sheet  or  bag  or 

place  in  a  sterilizing  drum. 

9.  Steam-sterilize  and  dry  in  autoclave.     (New  towels  should 

be  boiled  before  using,  to  prevent  stiffening.) 

ABSORBENT    AND    NON-ABSORBENT    COTTON. 

Cotton,  in  rolls,  pads  or  "  sponges  "  may  be  steam-steril- 
ized and  dried  in  an  autoclave. 

BORATED    COTTON. 

Immerse  sterilized  absorbent  cotton  in  a  saturated  aqueous 
solution  of  boracic  acid ;  wring  out  and  allow  to  dry  slowly. 


Preparation  of  Surgical  Gauze.  327 

PLAIN  gauze;  gauze  pads  and  sponges. 

If  ordinary  cheese-cloth  is  used,  it  is  boiled  in  soft  soap 
or  soda  to  remove  the  grease  and  make  it  absorbent.  After 
the  boiling  it  is  rinsed  and  dried,  folded  in  a  package  and 
sterilized  in  a  towel,  a  jar  or  a  canister,  in  an  autoclave  (250° 
F.,  fifteen  pounds  pressure,  at  least  fifteen  minutes). 
Sponges  and  pads  are  made  of  several  folds  of  gauze,  the 
edges  of  which  are  turned  in  and  hemmed  to  avoid  loose 
threads.  Abdominal  pads  should  have  a  narrow  tape 
strongly  sewed  to  one  of  the  corners.  Pads,  -ponges  and 
"packings"  (the  edges  of  which  are  similarly  folded  in) 
are  sterilized  in  packages  like  the  dressing  gauze. 


BICHLORID   gauze. 

Wring  out  sterile  gauze  in : 

hydrarg.  chlorid.  corrosiv gr.  x 

sodium  chlorid 3  ss 

acid  citric 5  i 

glycerin O  ss 

aq.  destillat O  ii 

(Enough  for  sixty  yards.) 
Keep  moist  or  dry  in  sterile  jars,  well  stoppered.     The 
citric  acid  and  sodium  chlorid  are  added  to  the  solution  to 
prevent  decomposition  of  the  mercurial  salt. 

(Formula  from  Senn's  "  Nurse's  Guide.") 


CARBOLIZED   GAUZE. 

Wring  out  sterile  gauze  in : 

acid  carbolic I  iii 

glycerin 3  xviv 

aq.  destillat O  ii 

(Enough  for  sixty  yards.) 
Preserve  the  same  as  sublimate  gauze. 

(Formula  from  Senn's  "Nurse's  Guide.") 


328  The  Surgical  Assistant. 

iodoform ized  gauze. 

(a).   I.  With  disinfected  hands,  wring  out  pieces  of  gauze 
in  aqueous  subHmate  sokition,  1-500. 

2.  Shake  pieces  out  loose  and  mix  them  thoroughly, 

one  by  one,  and  then  altogether  in 

powdered  iodoform o  i 

glycerin f  i 

aq.  sublimate  solution,  i-iooo.  ...  3  xxxii 

(This  quantity  is  enough  for  sixteen  yards.    The 
mixture  makes  a  3  per  cent,  gauze). 

3.  Fold  in  packages ;  sterilize  in  towel  or  jar  in  the 

autoclave.  (Mt.  Sinai  Hospital,  N.  Y.) 

(b).  I.  Soak  gauze  uniformly  in  a  mixture  of 

iodoform    20  parts 

glycerin    20  parts 

alcohol    70  parts,  by  weight 

(5  per  cent,  mixture.) 

2.  Wring  out  as  dry  as  possible. 

3.  Fold  in  packages  or  rolls ;  place  in  aseptic  jars  and 

seal  hermetically. 

(c).  I.  Place  sterile  gauze  in  20  per  cent,  ethereal  solution 
of  iodoform  for  ten  minutes. 

2.  Wring  out  and  place  in  basin  covered  with  sterile 

towel  to  allow  ether  to  evaporate.     (Gauze  now 
greenish-blue.) 

3.  Soak  twelve  hours  in  aqueous  sublimate   solution, 

1-4000.    (Gauze  restored  to  yellow  color  and  anti- 
septic.) 

4.  Wring  dry  as  possible. 

5.  Fold;  place  in  sterile  jars.  (Pryor's  Method.) 

To  improve  the  Color  of  lodoformized  Gau:;e, — 

For  each  thirty  yards  add  to  the  mixture  about  a  dram  of 
tincture  of  curcuma,  prepared  thus :  Mix, 

powdered  curcuma ^  iv 

proof  spirit.  , , , i  pint 


Formulary.  329 

Let  stand  until  clear ;  pour  off  clear  liquid ;  add  spirit  until 
all  color  is  extracted.      (From  Senn's  "  Nurse's  Guide.") 

IODOFORM    EMULSION. 

Use  iodoform,  i  part;  glycerin,  9  parts  (by  volume  or 
weight). 

Boil  the  glycerin,  pour  it  into  sterile  bottle,  allow  it  to 
cool,  add  iodoform,  cork  with  sterile  stopper,  shake. 

IODOFORM -ETHER. 

A  saturated  solution  of  iodoform  in  sulphuric  ether. 

lODOFORM-COLLODION. 

Iodoform,  gr.  xlviii;  collodion,    |  i. 

STRONGER    lODIN    TINCTURE. 

lodin  crystals 2  parts 

"h^ 5parts 

Keep  in  glass-stoppered  bottle.  This  is  twice  the  strength 
of  the  officinal  tincture.  (Elsberg.) 

BALSAM    OF    PERU    AND    CASTOR   OIL  (oiLY   DRESSING). 

Mix  Peruvian  balsam,  i  part,  and  castor  oil,  10  parts ;  pour 
into  clean  bottle ;  plug  neck  with  cotton ;  sterilize  in  auto- 
clave.   This  is  poured  on  the  gauze  when  needed. 

LIQUOR   ALUMENI   ACETATIS 
(bUROW's    SOLUTION    FOR    WET   DRESSINGS). 

Plumbi  acetate 3.50 

alumen 9.0 

aq.   ad loo.o 

Mix  and  filter.  Dilute  for  use  with  five  to  eight  times  as 
much  water.  Maceration  and  whitening  of  the  skin,  especi- 
ally of  the  hand  and  foot,  by  the  application  of  gauze  mois- 
tened in  this  solution,  may  be  prevented  by  adding  to  the 
solution  about  one-sixth  its  bulk  of  glycerin  or  alcohol. 


330  The  Surgical  Assistant. 

Thiersch's  solution  (for  wet  dressings  and  irrigation). 

Salicylic  acid 3  ss  ( i  part) 

boracic  acid 3  iii  (6  parts) 

water O  ii  (500  parts) 

plain  boracic  acid  solution. 

Boracic  acid 4  parts 

water 100  parts 

(Saturated  solution.)      Boracic  acid  crystals  dis- 
solve more  readily  than  the  powder. 

saline  solution. 

Physiologic  Salt  Solution  : 

Sodium  chlorid 138  grains  ;  9  grams 

water i  quart ;  i  liter 

"Balanced"  Physiologic  Salt  Solution: 

Sodium  chlorid 0.90 

potassium   chlorid 0.03 

calcium   chlorid 0.02 

water  100.00 

SUBLIMATE    SOLUTIONS. 

1:10,000  1:1,000 

bichlorid  of  mercury,  gr.  i;^;  o.  1  15  grains;  i  gram 

water  ...    1  quart;  i  liter  i  quart;  i  liter. 

1:500  25^  stock  solution 

bichlorid  of  mercury,  gr.  xxx;  2.0  8  ounces;  250  grams 

water  .,,.1  quart;  i  liter  i  quart;  i  liter 

1:1000  1:500 

1^%  stock  solution,  3  i;  4  c.c.  3  ii;  8  c.c. 

water 1  quart;  1  liter  i  quart;  1  liter 

Commercially  prepared  tablets  containing  7^  grains  of 
the  mercurial  salt  (and  citric  or  tartaric  acid)  yield  a  i-iooo 
solution  in  a  pint  of  water. 


Formulary.  831 


CARBOLIC   ACID    SOLUTIONS. 

Phenol  crystals  are  liquified  by  setting  the  bottle  in  which 
they  are  sold  in  hot  water ;  to  hasten  the  process  a  teaspoon- 
ful  of  hot  water  may  be  poured  into  the  neck  of  the  bottle. 

I  per  cent.  2  per  cent.  5  per  cent. 

(saturated  solution) 
pure  carbolic  acid,  3  iiss;  10  c.c.   3v;  20  c.c.  3xiiss;  50  c.c. 

water i  quart;  i  liter  i  quart;  i  liter     i  quart;  1  liter 

CREOLIN    AND   LYSOL   SOLUTIONS. 

I  per  cent.  2  per  cent, 

creolin;  lysol,3  iiss;  10  c.c.  3  v;  20  c.c. 

water i  quart;  i  liter.  i  quart;  i  liter. 

FORMALDEHYD   SOLUTIONS. 

I  per  cent.                               3  per  cent,  formalin-glycerin, 
com'c'l  formalin,  3  vi^;  25  c.c.      com'c'l  formalin,  3  ivss;  18  c.c. 
water i  quart;  i  liter.        glycerin §  viii;  250  c.c. 

PICRIC   ACID   SOLUTION    FOR   BURNS. 

Picric  acid gr.  xxxviii ;  2.5  grams 

alcohol §  i ;  30.0  c.c. 

water, O  i ;  250.0  c.c. 

NITRATE   OF    SILVER   SOLUTIONS. 

T  per  cent.  5  per  cent, 

argent,  nitrate,  gr.  v;  0.3  grams.  gr.  xxv;  1.5  grams, 

aq.  destillat |  i ;  30  c.c.  §  i ;  30.0  c.c. 

It  is  important  that  the  solution  should  be  made  with  dis- 
tilled water  and  preserved  in  dark,  glass-stoppered  bottles 
that  have  been  rinsed  out  with  distilled  water. 

COCAIN    SOLUTIONS. 

}4  per  cent.  2  per  cent, 

cocain  hydrochlorate. . .  gr.  iiss;  0.15  gr.  x;  0.6  grams 

sterile  distilled  water. . . .  §  i ;  30.0  c  c.  §  i ;  30.0  c.c. 

To  preserve  the  solution,  a  few  grains  of  boracic  or  sali- 
cylic acid  should  be  added. 


332  The  Surgical  Assistant. 

schleich's  solutions  for  infiltration  anesthesia. 

No.  I  No.  2  No.  3 

(Strong)    (Normal)      (Weak) 

Cocain  hydrochlorate  gr.  ii  gr,  i  gr.  j^ 

morphin  hydrochlorate  gr.  %  S^-  H  S^-  A 

sodium  chlorid,  c.  p.  gr.  ii  gr.  ii  gr.  ii 

sterile  water  (about  §  ii)  -m  ^°°°  ITl  ^°<^  TTL  ^0°° 

SOLUTIONS    FOR    ELECTRIC    BATTERIES. 

Carbon-zinc  Galvanic  "  Dip  "  Battery. 

Sulphuric  acid 4  ounces 

potassium  bichromate,  enough  to  saturate. 

water i    quart 

Have  the  cells  half  full. 

Leclanche  Battery. 

Copper  pole  tightly  packed  in  a  porous  receptacle  with  a 
mixture  of  manganese  dioxid  and  gas  carbon  covered  with 
pitch ;  zinc  pole  dipping  in  solution  of  sal  ammoniac. 

To  replenish,  wash  glass  cell  clean,  put  in  fresh  zinc  rod 
if  needed,  and  fill  jar  one-third  its  depth  with  a  strong 
solution  of  sal  ammoniac  (ammonium  chlorid) — about  six 
ounces  to  the  quart  of  water. 

Gravity  ("  Crozvfoot" )  Battery  for  charging  storage  cells. 

Copper  pole  in  copper  sulphate  solution  at  the  bottom ;  zinc 
pole  near  the  top  of  the  solution. 

Blue  vitriol  (copper  sulphate)  is  placed  in  generous  quan- 
tity at  the  bottom  of  the  cell,  and  enough  water  is  poured  in 
to  nearly  fill  the  jar.  A  little  common  salt  or  sulphuric  acid 
is  added  to  the  zinc  to  start  the  action  of  the  battery. 

enemata. 

Cathartic  Enema. 

This  consists  ordinarily  of  plain  warm  water  or  water 
in  which  a  lather  is  made  with  (Castile)  soap.  To  it,  es- 
pecially when  administered  "  high,"  various  elements  may  be 
added  according  to  the  indication,  e.  g.,  olive-  or  cotton-seed 


Formulary.  333 

oil,  six  to  eight  ounces ;  magnesium  sulphate,  one  ounce ; 
inspissated  ox-gall,  a  tablespoonful ;  and,  to  relieve  tympan- 
ites :  peppermint  water ;  spirits  of  turpentine,  one  or  two  tea- 
spoonfuls  ;  tincture  of  asafoetida,  one-half  to  one  ounce,  etc. 

Stimulating  Enema. 

Tinct.  digitalis Ttl,xx 

whiskey ^  i 

table  salt 3  ss-  3  i 

water 3  viii-O  i 

(tinct.   opium tT^xx) 

Nutritive  Enema. 

A  combination  such  as  that  of  some,  or  all,  of  the  follow- 
ing :- 

^gg  --^ • I 

peptonized  milk 2  iv-vi 

beef  extract,  peptonoids  or  somatose .  .  1  i-ii 

whiskey ^  i 

salt  solution variable 

(tinct.  opium , TT|,x-xx) 


APPENDIX    II. 


Surgical  Instruments. 


337 


Fig.  3. — Bennett's  apparatus  for  the  administration  of  gas  and  ether.  A,  Air-trap 
in  face-piece;  B,  ether  chamber;  D.  chamber  containing  valved  tubes  for  transmits 
ting  nitrous  oxid  gas;   E,  air-trap;  F,  stop-cock  for  introducing  gas  into  balloon. 


Fig.  4. — Ware's  ethyl  chlorid  mask,    a,  face-piece,  b,  metal  tube;    c,  section 
showing  insertion  of  gauze. 


338 


The  Surgical  Assistant. 


Fig.  6. — Paquelin  cautery. 


Fig    7  — Gerster  s 
iodoform  duster 


Fig.  S.  — Dieulafoy's  aspirator. 


Fig.  9. — Trocar  and  canula. 


Fig.  jo. — Volkmann's  spoon. 


Surgical  Instruments. 


339 


340 


The  Surgical  Assistant. 


Fig.  23. —        Fig.  23.—  Fig.  24  — 

One-pronged   Two-pronged    Small  blunt 
retractor.  retractor  retractor. 


Fig.  25. — Large  (abdom- 
inal) blunt  retractor. 


Surgical  Instruments. 


.341 


Hagedora 
pattern 


i  HaPedora 


Fig.  2". — Forms  of  surgical  needles. 


Fig.  33. — Hagedorn  s  needle  holder. 


342 


The  Surgical  Assistant. 


Fig.  43.— Serrefins. 


Pie.  42. — Pean's  artery  {creeps. 


Surgical  Instruments. 


343 


Fig.  44. — Spencer  Wells' 
straight  clamp. 


Fig.  45. — Skene's 
curved  clamp. 


Fig.  46. — Spencer  Wells' 
T-shaped  clamp. 


Female  half.  Male  half.  Partly  closed. 

Fig.  48. — Murphy's  button. 


Fii;  49. — Tracheal  canula. 


Fig.  47. — Angiotribe. 


Fig.  50/— Nasal 
speculum. 


344 


The  Surgical  Assistant. 


"Fie.  57. — Bowman's  lachrymal  probes, 


Surgical  Instruments. 


345 


G  TIEMAUfl  t  a. 


Fig. '59. — Iris 
scissors. 


Fig.  (10. — Beer's  keratome. 


Fic.  63.— Levi's  fenestrated  lens  spoon. 


Fig.  64.— Wilde's  tubular  aural 
specula. 


Is 


Fig.  66. —Mastoid  mallet. 


ySfjfA^yi'PV   SCO 


iO 


Fig.  67. — Mastoid  chisels. 

IflnnnmltiiHiitiHiiinmminiiiiiitC 


m 


Fig.  68. — Mastoid  gouge. 


Fig.  6g.— 
Keyhole  saw. 


346 


The  Surgical  Assistant. 


Fig.  71.— Ferguson's  lion-jaw  bone-holding  forceps. 


Fig.  72. — Markoe's  sequestrum  forceps. 


Fig.  74.— Costotome. 


Surgical  Instruments. 


347 


Fig.  77. — a.  Sharp  bone  spoon;  b.  Periosteal  eleyator. 


ENG     U  12  13  14  IS  15  16  17  _  17 

FRC   13  18  17  16        IS        1"        '•"        ^"      ^       '"       o      «       ' 


^trS    U  10  10  9  9         8         7         6         5       4- 


Fig.  7S.— French  and  English  urethral  scales. 


Fig.  79, — Olive-tipped  catheter. 


e.TIEMANN  &.C0. 


Fig.  80. — Olivary  bougie. 


Fig.  81.— Woven  catlieter. 


[Fig.  82. — Bougie  d  boule. 


348 


The  Surgical  Assistant. 


Fig.  64. — Filiform  bougiefc 


V. 


^■\^W\iAkH*.'PT  kW.tiCO. 


fiG..  S6.— Cltzniaiin's  urethral  syringe. 


I 


V 


Fig,  85. — Filiform 
bougies. 


C.TtEMAUrj  &  CO 


Fig.  S7.— Otis'  urethrometer. 


Fig.  88. — Thompson's  stone  searcher. 


a.  riEi\f/iNH.  ecu.  1 
Fig.  89. — Thompson's  lithotrite. 


Fid.  ^z.t-Maisonneuve's  urethrotome. 


Surgical  Instruments. 


349 


i^ 


Fig.  94. — Wheel- 
'    J  house's  stafE.      p^^  gs.JlTeale's. 

^  I  probe   gorget  (ure- 

W  thral  director). 

Fig.  93.— En-  t^        .      c* 

doscope.  ,  Fig.  96.~Stone 

forceps. 


FiG.  (,7.— Clover's  crutch  (Peter's). 


350 


The  Surgical  Assistant. 


Fig.  98.—  Fig.  99.— 

Tenaculum.        VoIseUum 


riu.  102. —  Fig..  103. — 

Sharp  Dull  uterine 

uterine  curette, 
curette. 


Fig.  105. — noodell's  cervix  dilator. 


Surgical  Instruments. 


351 


Fig.  io6.— Recurrent- 
uterine  douche  nozzle. 


KiG.  107. — Sims' 
vaginal  depressor. 


FiG.  108  — Garrignes' 
weighted  speculum. 


Fig.  109. — Vaginal  spatula,  with  author's  cervix-elevating  attachment. 
a,  und«r  surface;  b,  upper  surface. 


Fli'..  no. — Ferguson's  cylindrical 
vagina!  speculum. 


Fir,.  III.— Sims'  vaginal  speculum. 


352 


The  Surgical  Assistant. 


V.     A 


Fro.  112.— Brewer's  bivalve  vaginal  speculum. 
A,  open;  B,  closed. 


Fig.  113. — Bivalve  rectal  speculum. 


Fig.  114.— Ashton's  fenestrated  rectal  speculum. 


Fig.  115.— Smith's  pile  clamp. 


Fig.  116.— English 
rectal  bougies.' 


INDEX. 


INDEX. 


Abscess,  hepatic,  205 

pelvic,  266 

retropharyngeal,  178 

subphrenic,  205 
Abdominal  dressing,  193 

wall,  dissection  of,  184 

operations  {see  Laparotomy) 
Abortion,    incomplete,    curet- 
tage in,  261 
A.  C.  E.'  mixture,  83 
Adenoids,  removal  of,  177 

choice  of  anesthetic  for,  82 
Adhesive   plaster,    application 
of,  over  abdominal  dress- 
ing. 193 

removal  of,  52 

sterile  strips,  192 
Adrenalin  in  narcosis,  93 

in  post-operative  shock,    152 
Albert's  gastrostomy,  208 
Alcohol  sterilization  of  catgut, 

317 

Alcoholics,  in  general  narcosis, 

85 
choice  of  anesthetic  for,  82 
Alexander's  operation,  225 
Allingham's  operation,  283 
AUis  inhaler,  96,  337 
Aluminum     acetate     solution, 

329 
instruments,  sterilization  of, 
102 
Amputation  of  breast,  180 
of  digit,  295 
of  extremity,  286 
osteoplastic,  293 
Anamnesis,  34 
Anastomosis,  intestinal,  212 

lateral,  214,  216 
Anesthesia,  local,  cocain  solu- 
tions, 331 
Sclileich's  mixtures,  332 
mixtures,  83,  97 
paralysis,  86 
sequence, 83 


Anesthetic,  choice  of,  81 
Anesthetist,  the,  81 

armamentarium,  62,  83 

in  cranial  operations,  163 
Anesthol,  83 

Antiseptics,  poisoning  by,  159 
Anus,  stretching  the,  278 
Appendicitis,  abscess,  198 

interval  operation,  196 
Applicator,  129 

Arms,  position  of  during  nar- 
cosis, 86 
Arteriosclerosis,  in  narcosis,  82 
Artificial  respiration,  91 
Asepsis,  technics  of,  72 
Aseptic  "  don'ts  ",  79 
Aspirating  needles,  care  of,  11 1 
Aspiration,  pleural  cavity,  181 

preparations  for,  28 
Atropin  in  narcosis,  84,  91 

in  singultus,  150 
Axilla,  pads  for,  42 

Bandage,  crinolin,  44 
dextrin,  44 
eye,  174 
-knife,  112 
plaster  of  Paris, 
application  of,  45 
preparation  of,  325 
preservation  of,  46,  325 
removal  of,  50 
starch,  44 

preparation  of,  326 
T-,  252 
Basins,  for  an  operation,  57 

sterilization  of,  56 
Bassini's  operation,  227 
Basswood  veneering,  43 
Batteries,  care  of,  112 

solutions  for,  332 
Bed,  arrangement  of ,  in  shock, 

151 
preparation  of,  148 
Bennett's  inhaler,  97,  337 


355 


356 


Index. 


V.  Bergmann's  catgut  steriliza- 
tion, 314 
Bichlorid  of    mercury   gauze, 

327 
solutions,  330 
catgut  sterilization,  314 
Bier's  osteoplastic  amputation, 

293 
Billroth 's  anesthesia  mixture, 

83 
Binder,  abdominal,  194 

T-,  252 
Bladder,   drainage   of,    supra- 
pubic, 248 
perineal,  249 
hemorrhage  from,  155 
neoplasm  of,  248 
operations,  241 
preliminary      preparation 
for,  313 
ulcer  of,  248 
Boeckmann's  catgut  steriliza- 
tion, 319 
Bone  chips,  Senn's,  324 
filling,      Mosetig-Moerhof's, 

324 
wax,  Horsley's,  preparation 
of,  325 
Boracic  acid  solutions,  330,  171, 

174 
Borated  cotton,  326 
Bougies,  348 

care  of,  iii 

sterilization  of,  104 
Bowels,    preparation     of,    for 
operation,  311 

care  of,  post-operative,  312 
Brandy  in  general  narcosis,  93 
Breast  amputation,  180 
Button  suture,  119 
Burow's  solution,  329 

Caffein  in  narcosis,  93 
Camphor  as  a  stimulant,  93 
Canule  a  chemise,  156,  284 
Carbolic  acid,  poisoning  by,  159 

solutions,  331 
Carbolized  gauze,  327 
Cardboard  splints,  44 

pad,  triangular,  42 
Cargile  membrane,  301 
Carrying  a  patient,  68,  147 
Cataract  extraction,  171 


Cap,  surgeon's,  72 

patient's,  84,  166 

cleansing,  sterilization,  326 
Catgut,  chromicizing,  319 

preparation,  sterilization,  314 
Catheters,  care  of,  iii 

sterilization  of,  104 
Catheterization,  150,  312,  314 

of  female,  244 

of  male,  255 
Cautery,  care  of,  113 

Paquelin,  283,  338 
Celluloid  thread,  321 
C.  E.  mixture,  83 
Cervix    uteri,    anesthesia     in 
operations  upon,  93 

dilatation  of,  261 

discission  of,  263 

hemorrhage  from,  157 

trachelorrhaphy,  263 
Cesarean  section,  223 
Chloretone  in  narcosis,  84 
Chlorinated  lime  in  skin  disin- 
fection, 74 
Chloroform,  administration,  94 

drop  bottle,  62,  94 

indications  and  contra-indi- 
cations,  81 

mask,  62,  94,  337 
Cholecystectomy,  204 
Cholecystostomy,  202 
Cholecystotomy,  202 
Choledochotomy,  204 
ChoLemia,  155 
Chromicizing  catgut,  319 
Cigarette  drain,  123 
Clamp,    hemostatic,    136,    342, 
343 

operations  for  hemorrhoids, 
281,  283 
Claudius'  catgut  sterilization, 

315 

Clove  hitch,  124 

Clover's  crutch,  258,  349 
inhaler,  97 

Cocain  solutions,  331 
sterilization  of,  106 

Cock's  operation,  254 

Collapse,  in  first  stage  of  nar- 
cosis, 85 

Collodion,   application  of,  308 
iodoform-,  329 

Color,  during  narcosis,  87 


Index. 


357 


Colostomy,  inguinal  209 

lumbar,  211 
Colporrhaphy,  after-treatment, 

314 
anterior,  268 
posterior,  272 
Compress,  split,  122 
Conjunctival  reflex,  91 

in  ethyl  bromid  narcosis,  100 
Constrictors,    application     of, 
289,  296 
of  scalp,  164 
Convulsions,  uremic,  158 
Cotton,  absorbent,  sterilization 
of,  105,  326 
borated,  326 
Crane  tendon,  sterilization  of, 

321 
Cranium,  operations  upon,  163 
Creolin  solutions,  331 
Crinolin  bandages,  44 
Cumol  sterilization  of  catgut, 

317 
Cupping,  157 
Curettage,  260 

after-treatment,  313 

arrangement  of  instruments, 

115 
Cyanosis  during  narcosis,  85, 

87,  97 

in  nitrous  oxid  narcosis,  98 
Cystocele,  268 
Cystoscopes,  cleansing  of,  108 

sterilization  of,  103 
Cystoscopy,  female,  243 

male,  241 

preliminarypreparations,  313 
Cystotomy,  suprapubic,  244 

Digitalis,  in  narcosis,  93 
Discission  of  the  cervix,  263 
Disinfection  of  field  of  opera- 
tion, 69 
of  hands,  73 
Dislocations,  dressing  of,  41 
Dissection,  assistance  in,  135 
Drain,  cigarette,  123 

gauze,  121 
Drainage,  of  bladder,  perineal, 
249,  251 
suprapubic,  248 
tube,  preparation  of,  123 
Draw  sheet,  148 


Dressings,  renewal  of,  50 
tightness  of,  148 

Eclampsia,  158 
Ectopic  gestation,  220 
Edebohls'  nephropexy,  239 
Edema,  pulmonary,  157 
Elsberg's    catgut  sterilization 
method,  316 
catgut  chromicizing  method, 
320 
Emergency  operation,  prepa- 
ration of  patient  for,  314 
Empyema  of  the  gall-bladder, 
202 
thoracis,  181 
Endometritis,  curettage  in,  261 
Endoscopy,  243 

Enema,  in  retention  of  urine, 
150 
stimulating,  93,  152 
Enemata,  formulae  of,  332 
Enterorrhaphy,  208 

circular,  212 
Esophagotomy,  external,  178 

internal,  208 
Ether,  contra-indicationstouse 
of,  82 
hypodermatically,  93 
in  cleaning  instruments,  108 
masks,  63,  96,  337 
methods  of  administering,  96 
Ethyl  bromid  narcosis,  100 

chlorid  narcosis,  99 
Excitement,  in  ether  narcosis, 
96 
stage  of,  in  narcosis,  85 
External  urethrotomy,  252 
Extremities,  position  of,  dur- 
ing narcosis,  86 
in  bed,  148 
Eye,  cataract  operation,  171 
enucleation,  174 
iridectomy,  173 
signs  in  general  narcosis,  91 
strabismus,  173 

Feeding  after  operation,  149 
Fenwick's  operation,  246 
Fistula  in  ano,  284 
Flannel  bandages,  45 
Foot,  disinfection  of,  70 
holding,  for  dressing,  39,  49 


358 


Index. 


Formaldehyd  solutions,  331 
sterilization     of      catheters, 
104 
Formalin,  catgut  sterilization, 
318 
-glycerin,  104,  331 
Formol-iodin   catgut  steriliza- 
tion, 319 
Formulary,  314 

Fountain   syringe,  manner  of 
suspending,  62 
preservation  of,  rii 
sterilization  of,  104 
Fracture,    countertraction     in 
reduction  of,  40 
depressed,  of  cranium,  164 
dressing  of,  41 

Gall-bladder,  operations  upon, 

202 
Gall  ducts,  hemorrhage  from, 

155 
operations  upon,  204 
Galvano-puncture,  holding  pa- 
tient for,  39 
Gas-ether  narcosis,  97 

sequence,  83 
Gas-oxygen  narcosis,  99 
Gasserian    ganglion,    excision 

of,  165 
Gastrectomy,  209 
Gastric  lavage,  200 
Gastro-enterostomy,  209,  215 
Gastrorrhaphy,  208 
Gastrostomy,  207 
Gauze,  bichlorid,  327 
carbolized,  327 
drains  and  packings,  121 
iodoformized,  328 
sterilization  of,  105,  327 
Gavage,  201 

Genu-pectoral  position,  244 
Gigli  wire  saw,  care  of,  109 

manner  of  using,  293 
Gloves,  cotton,  77 
rubber,  application  of,  75 
sterilization  of,  75 
preservation  and  repair  of, 
112 
Gown,  cleansing  and  steriliza- 
tion, 326 
how  to  put  on,  75 
Granny  knot,  139 


Gutta-percha,    Murphy's  solu- 
tions of,  77,  184 
preparation  of,  324 
sterilization  of,  105,  323 

Guy  thread,  141,  245 

Hagedorn  needle,  116,  341 
Halsted  suture,  214 
Hands,  disinfection  of,  73 

proper  use  of,  130 
Head,  position  of   in   trephin- 
ing, 164 
and  neck,  narcosis  for  opera- 
tions upon, 95 
Hematocele,  220 
Hemorrhage,     after-treatment 
of,  157 
concealed,  7js.  shock,  151 
intra-abdominal,  154 
Hemorrhoids,  after-treatment, 
312 
operations  for,  2S1-2S4 
Hemostasis  in   operating,    136 
Heron  tendon,  321 
Herniotomy,  femoral,  234 
inguinal,  227 

congenital,  228,  230 
narcosis  in,  93 
ventral,  226 
Hiccough,  150 
History-taking,  34 
Hofmeister's   catgut    steriliza- 
tion, 318 
Horsehair,     sterilization,     105, 

321 
Horsley's  bone  wax,    106,  295, 

325 
Hospital  interne,  32 
Hospital  records,  care  of,  36 
Hot  packs,  158 

Hot  water  bags,  in  retention  of 
urine,  150 
precautions  in  use  of,  148 
House     surgeon,     duties     of, 

32 
Hydronephrosis,  238 
Hypodermatic  injections,  tech- 

nic  of,  106 
Hypodermoclysis,  308 
Hysterectomy,  abdominal,  220, 
223 
vaginal,  265 
after-treatment,  314 


Index. 


359 


Incision,  the,  131 
Infusion  canula,  cleansing  of, 
108 

intravenous,  alkaline,  304 
saline,  93,  153,  3oi 

rectal,  93,  333 

subcutanous,  saline,  308 
Inhaler,  chloroform,  94,  337 

ether,  96,  337 

ethyl  chlorid,  99,  337 

gas-ether,  97,  337 
Instrument  table,  66 
Instruments,  arrangement  of, 

114 

cleansing  and    preservation 
of,  107 

manner  of  handing,  124 
Intercostal     vessels,      hemor- 
rhage from,  154 
Intestinal  anastomosis,  212 

resection,  211 
Intestines,  perforation  of,  208 

preparation    of,    for    opera- 
tion, 311 
Intracranial  operations,  163 

choice  of  anesthetic  for,  82 
Intravenous  infusion  {see  Infu- 
sion) 
Invalid's  table  for  instruments, 

61 
lodin  in  vomiting,  149 

stains,  removal  of,  109 

tincture,  stronger,  329 
lodoform-coUodion,  329 

emulsion,  329 

-ether,  184,  329 

gauze,  328 

poisoning,  159 
Iridectomy,  173 
Irrigating,  144 

solution,  preparation  of,  62 
Irrigator,  62 

Jaw,  management  of,  in  nar- 
cosis, 89 
upper,  removal  of,  175 

Kader's  gastrostomy,  208 

Kammerer's  abdominal  inci- 
sion, 186 

Kangaroo  tendon,  sterilization 
of,  320 

Kelly  pad,  60 


Kelly-Pawlik  cystoscopy,  243 
Kidney,  hemorrhage  from,  155 
operations  upon,  235 

abdominal  route,  239 

choice  of  anesthetic  for,  82 

lumbar  route,  235 

position  of  patient  for,  235, 

239 
Knot,  Staffordshire,  140 

varieties  of,  138 
Kronig's   catgut    sterilization, 
317 

Laparotomy,    after-treatment, 
312 
arrangement  of  instruments 

for,  115 
exploratory,  196 
pads,  122 
preparation  for,  preliminary, 

312 
preparation  of  field  for,  70,184 
straps,  193 
Laughing  gas,  administration 
of,  98 
and  ether,  97 
Lavage,  gastric,  84,  200 
Leg-holder,  brachial  palsy  pro- 
duced by,  86 
improvised,  60 
Edebohls',  258 
Lembert  sutures,  198,  213,  214, 
Ligating  in  continuity,  136 
Ligature,  116,  138 
"  chain,"  140 
"  mass,"  140 
rubber,  140 

McGraw's,  215 
"  side,"  137 
varieties  of,  138 
Lithotomy,  perineal,  254 
position,  241,  257 
suprapubic,  246 
Liver,  abscess  of,  205 
cyst  of,  205 
hemorrhage  from,  155 
tumor  of,  205 
Lysol  solutions,  331 

Marcy's  kangaroo  tendon  ster- 
ilization, 320 
Marwedel's  gastrostomy,  208 
Mask  {see  Inhaler) 


360 


Index. 


Mass  ligatures,  117 
Mastoid,  operations,  166 

dressing,  170 
Maunsell's  operation,  213 
Maxilla  {see  Jaw) 
McBurney's  intermuscular  dis- 
section, 185 

skiu-grafting  retractors,  300 
McGraw  rubber  ligature,  215 
Meatotomy,  242 
Mercury,   bichlorid  of,  poison- 
ing by,  159 
solutions,  330 
Mikulicz  bag,  122 
Morphin  after  operations,  148, 

311 
in  narcosis,  84,  85,  92,  93 
in  pulmonary  edema,  157 
in  singultus,  150 
in  vomiting,  149 
Morris  drain,  123 
von     Mosetig-Moerhof's    bone- 
filling,  324 
Mouth  cover,  72 
operations,  method  of  chloro- 
formizing  in,  95 
preliminary       preparation 
for,  313 
Murphy's  button,  215,  342 
gutta-percha     solutions,     77, 

184,  324 
rubber  dam,  77,  184 

Nails,  disinfection  of,  7-5 
Narcosis  {see  Anesthesia) 
Neck,  operations  upon,  178 
Needles,    aspirating,    care    of, 
III 

care  of,  108 

sterilization  of,  102 

hypodermatic,     sterilization 
of,  106 

varieties  of,  116,  341 
Needle  holders,  120,  126,  341 
Nephrectomy,  235,  236 

hemorrhage  after,  155 
Nephropexy,  236,  239 
Nephrotomy,  236,  238 

hemorrhage  after,  155 
Nitroglycerin  in  narcosis,  93 

in  pulmonary  edema,  157 
Nitrous  oxid  narcosis,  98 
Nose,  hemorrhage  from,  153 


operations  upon,  preparation 
for,  313 
Nourishment   after  operation, 
149.  312 

Nurse,  duties  of,  33 

Obstetric  narcosis,  100 
Omentum,  ligating,  140 
Operating  room,    preparation 
of,  58 
selection  of,  53 
table,  58 
for  perineal  operations,  60 
Operation,  supplies  for,  54 
Ophthalmic  instruments,  steri- 
lization of,  103 
testing,  107 
operations,  171 
sutures,  118,  173 
Ormsby's  inhaler,  97 
Osteotomy,  arrangement  of  in- 
struments for, 115 
for  osteomyelitis,  296 
Ovariotomy,  218 
Oxalic  acid  in  hand  disinfec- 
tion, 74 
Oxygen,  employment  of,  157 
in  nitrous  oxid  narcosis,  99 

Packings,  121 

abdominal,  190 

preparation  of,  327 
Packs,  hot,  158 
Padding,  pressure,  42 

protective,  41 
Pads,  abdominal,  190 

axillary,  42 

preparation  of,  327 
Paquelin  cautery,  113,  197,  281, 

338 
Paraffin  paper,  323 

preparatioii  of,  for  injection, 

325 
Paralysis,  narcosis,  86,  148 
Pedicles,  ligating,  140 
Pelvis,  drainage  of,  262 
Perineal   operations,   arrange- 
ment  of  table  for,  60 
preparation  for,  257 
section,  252 
Perineorrhaphy,  272 
after-treatment,  314 


Index. 


361 


Perineum,   hemorrhage    from, 

156 
Peritonitis,  general,  200 
Peruvian    balsam  and    castor 

oil,  329 
Pharynx  {see  Throat) 
Phlebotomy,  158 
Physiologic     saline     solution, 

299.  304 
Phosgen,  95 
Picric  acid  solution,  331 
Plaster  of  Paris,  application  of, 

45 
bandages,  preparation  of,  46, 

325 

compression  by,  48,  149 

preservation  of,  47,  325 

protection  from  soiling   by, 
29.  45 

removal  of,  50 
Plastic  operations,  vaginal  and 

perineal,  268 
Position,  knee-chest,  244 

kidney,  235 

lateral,  182,  235 

lithotomy,  257 

Rose's,  175,  177 

Sims',  257,  277 

Trendelenburg's,  60,  218 

ventral  decubitus,  239 
Post-operative  care  of  patient, 

143.  3" 
Post-partum  hemorrhage,    156 
Potassium  permanganate,  de- 
colorization  of,  11 1 

disinfection  by,  74 
Preparation     of     patient     for 

operation,  routine,  311 
Pressure  paralysis  during  nar- 
cosis, 86,  148 
Probe,   method  of  straighten- 
ing, 109 
Prostatectomy,  perineal,  254 

suprapubic,  245,  247 
Pulmonary  edema,  157 
Pulse  in  narcosis,  87 

in  hemorrhage,  151 

in  shock,  151 
Pupil  in  narcosis,  84,  92,  100 
Purse-string  suture,  215,  230 
Pyloroplasty,  209 
Pylorectomy,  209 
Pyonephrosis,  238 


Pyosalpinx,  219 

Quilled  suture,  120 

Rectocele,  272  . 
Rectum,  examination  of,  277 
hemorrhage  from,  156 
operations  upon,  237 
narcosis  in,  93 
after-treatment  of,  312 
stricture  of,  284 
Reef  knot,  138 
Reflex,  anal,  93 
conjunctival,  91 
corneal,  92 
pupillary,  92 
Reinforcing  strips,  44 
Respiration,   cessation   of,    in 
narcosis,  first  stage,  85 
second    stage, 

91 
in  narcosis,  89 

Restlessness,      post-operative, 
148 
in  hemorrhage,  151 
Restraint,  employment  of,   in 

narcosis,  85 
Retracting,  133 
Retractors,  340 

cloth,  287 
Rib,  resection  of,  183 
Room,  after  operation,  148 
operating,  arrangement    of, 
58 
selection  of,  53 
Roseola  in  etherization,  97 
Rose's  position,  175,  177 
Rounds,  hospital,  36 
Rubber  bandage,  112,  287 
constrictor,  287 
dam,  77,  184 
gloves,  75,  1X2 
ligature,  140 

McGraw's,  215 
materials,    preservation    of, 
112 
sterilization  of,  104 
tissue,    sterilization    of,    64, 

105,  323 
tube  drains,   preparation  of, 
123 
sterilization  of,  323 
Rust,  log 


362 


Index. 


Saline  solution,  299,  330 

(see  Infusion) 
Salpingectomy,  218 
Saul's  catgut  sterilization,  317 
Saws,  care  of,  109 

employment  of,  292 
Scalpels,  cleansing  of,  107 

sterilization  of,  102 
Schede's  operation   for     oste- 
omyelitis, 294 
Schleich's    general  anesthesia 
mixtures,  83,  97 

local    anesthesia    mixtures, 
332 
Scissors,  care  of,  108 

manipulation  of,  138 
Scultetus  binder,  195 
Senn's  bone  chips,  324 

bone  plates,  217 

catgut  sterilization,'  318 
Shock  during  operation,  88,  93 

post-operative,  151 
Silk  sutures,  118 

sterilization  of,  105,  321 
Silkworm-gut  sutures,  118 

sterilization  of,  105,  322 
Silver  filigree,  226 

nitrate,  fused,  129 
solutions,  331 
stains,  109 
Sims'  position,  257,  277 

speculum,  257,  351 
Singultus,  150 
Skin-grafting,  299 
Smith's  operation,  281 
Soap  poultice,  311 
Soluble  glass,  326 
Sounds,  care  of,  109 

introduction  of,  255 
Splints,  43 

sterilization  of,  106 
Sponge  holder,  129,  342 
Sponge,  cotton,  128 

gauze,  preparation  of,  327 

manipulation  of,  in   wound, 
132 
in  mastoid  operations,  167 

manner  of  handing,  128 

on  a  string,  279 

sea-,  sterilization  of,  322 
Ssabanijews  -  Franck    gastros- 
tomy, 208 
StafiEordshire  knot,  140 


Starch  bandages,  44,  326 
Status  lymphaticus,  82,  177 
Sterilization  of  basins,  55 

of  instruments,  102 

of  towels,  55,  326 

of  surgical  materials,  314 
Stertor  in  narcosis,  85,  89,  97, 

100 
Stimulants  in  narcosis,  93 

in  post-operative  shock,   152 
Stockinet,  46 
Stomach,  lavage  of,  200 

operations  upon,  207,  312 
Strabismus,  173 
Strychnin  {see  Stimulants) 
Sublimate   solutions  (see  Mer- 
cury) 
Surgeon's  knot,  139 
Sutures,  117 

button,  119 

Halsted,  214 

Lembert,  198,  213,  214,  215 

manner  of  handing,  120 

purse-string,  215,  230 

quilled,  120 

removal  of,  144 

threading,  on  needle,  118 

wire,  105,  118 
Suturing,  141 

abdominal  wall,  191 
Sylvester's    artificial     respira- 
tion, 91 
Syme's  operation,  253 
Syringes,  repair  and  cleansing 

of.   III 

sterilization  of,  103,  104 
testing  of,  109 

T-bandage,  252 
T-tube,  248,  266 
Tampon  canula,  156,  279 
Thiersch's  skin-grafting,  299 

solution,  330 
Thomas'  operation,  283 
Thorax,  operations  upon,   180 
Throat,  care  of,  in  narcosis,  90 

examinations,  38,  39 

operations,  177 
choice  of  anesthetic  for,  82 
Tongue  in  narcosis,  89 

traction,  Laborde's,  91 

in  singultus,  150 
Tonsil,  hemorrhage  from,  154 


Index. 


363 


removal  of,  choice   of  anes- 
thetic in,  82 
Tourniquet,  286 

in  pulmonary  edema,  157 
Towels,  arrangement  of,  71 

cleansing,  326 

sterilizing,  55,  326 
Tracheotomy.  175,  178,  179 

canula,  342 
narcosis  through,  96 
Trachelorrhaphy,  263,  313 
Transportation  of  patient,  68, 

147 

Trap-door  incision,  186 

Traumatacin,  324 

Trendelenburg's  position,    60, 
218 

Trephining,  163 

Truax'  kangaroo  tendon  sterili- 
zation, 320 

Tube,  drainage,  123,  266,  323 
petticoated,  284 

T-,  248,  266 

Thyroidectomy,  178 

Tympanites,  313 

Undine,  171 

Uremia,  158 

Ureter,  operations  upon,  240 

Urethral  instrumentation,  255, 

313 
Urethroscopy,  243 
Urethrotomy,  combined,  251 

external,  252 

internal,  250 


Urination  after  operations,  150 

Uronephrosis,  238 

Uterus,  hemorrhage  from,  156 

round  ligaments  of,  shorten- 
ing the,  225 

{see  also  Hysterectomy) 


Vagina,  operations  in,  257,  313 
Vein,  clamping,  in  continuity, 

137 
Vinegar,  in  vomiting  after  nar- 
cosis, 149 
Vollmer-Kossman  catgut  steri- 
lization, 318 
Vomiting  after   operation,  149 
choice  of  anesthetic  to  min- 
imize, 82 
during  narcosis,  88,  93 


Water  glass,  326 

Wax,  bone-,  106,  295,  325 

paper,  preparation  of,  323 
Wet   dressings,    formulae    for, 

329,  330 
Wheelhouse's  operation,  253 
Whiskey  in  narcosis,  93 

in  shock,  152 
Whitehead's  operation,  283 
Window  panes,  soaping,  62 
Wire  mesh,  226 

sutures,  105,  118 
Witzel's  gastrostomy,  207 
Wyeth's  amputation,  286 


4 


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Printed 
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Briokner 

The  surgical  assistant 


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The  surgical  assistant,  a  manual  for  stu 


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